Investigator, Special Investigations Division

4 days ago

Des Moines, IA, United States Prime Therapeutics Full time

At Prime Therapeutics, we are transforming the role of pharmacy benefits managers (PBM). We are looking for enthusiastic individuals committed to making an impact and ready to embark on a fulfilling career. Be a key part of reshaping the future of pharmacy care

Position Overview

The Investigator for the Special Investigations Division (SID) is essential in combating fraud, waste, and abuse (FWA) within pharmacy, member, and prescriber activities. This role requires meticulous claims data analysis, fraud detection, auditing, and oversight to proactively improve investigation processes and preventive measures against FWA. You will prepare detailed investigative reports for leadership and, when necessary, refer findings to state and federal law enforcement agencies.

Key Responsibilities

  • Develop and execute investigative strategies, documenting justifications and adjusting to new discoveries to guarantee thorough coverage for each case.
  • Collect and evaluate factual evidence such as invoices, interviews, and documentation to substantiate investigation results.
  • Analyze reports of suspected fraud and provide guidance on actionable next steps, ensuring adherence to departmental policies.
  • Maintain compliance with evidentiary standards while navigating federal and state laws and considering risks associated with investigation findings.
  • Propose appropriate actions, including referrals to regulatory bodies or law enforcement, and recommend the retention of external expertise when necessary.
  • Perform additional duties as assigned.

Minimum Qualifications

  • Bachelor's degree in Criminal Justice, Healthcare, or a related field, or an equivalent combination of education and experience; a high school diploma or GED is required.
  • At least 2 years of experience in investigations, audits, healthcare, or legal environments.

This position requires eligibility to work in the United States without the need for visa sponsorship.

Additional Qualifications

  • Versatile mindset with the ability to adjust to evolving business priorities independently.
  • Strong critical thinking skills to evaluate complex situations, providing informed risk assessments to stakeholders.
  • Excellent interpersonal skills to build trust and collaborate effectively across multiple levels within the organization and external partners.
  • Outstanding communication skills to simplify complex concepts effectively.
  • Knowledgeable in the pharmacy and medical claims processing environment.

Preferred Qualifications

  • Professional certifications such as Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).
  • National Pharmacy Technician Certification (CPhT) or relevant nursing licensure (LPN/RN).
  • Experience with the RxClaims system or similar tools.
  • Background in pharmacy operations across various settings.
  • Skills in data mining and Excel proficiency.

All employees must be aware of, comply with, and affirm adherence to security responsibilities and controls relevant to their roles, along with legal and regulatory requirements.

The expected pay range for this position is $59,000.00 - $94,000.00 based on experience and skills.

Prime Therapeutics is proud to be an equal opportunity employer committed to diversity. We invite all qualified candidates to apply, and we consider applicants without regard to race, color, religion, gender, national origin, disability, age, veteran status, or any other legally protected class. We welcome individuals with diverse backgrounds, experiences, and perspectives.

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