[Remote] SIU Specialist/Pharmacy Tech - Remote in the California market

Note: The job is a remote job and is open to candidates in USA. Prime Therapeutics is a unique pharmacy benefit manager focused on connecting care for those they serve. The Associate SIU Specialist is responsible for handling allegations of fraud, waste, or abuse, conducting preliminary investigations, and maintaining compliance with relevant regulations.

Responsibilities

• Intake and maintain caseload of FWA incidents/allegations; prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements
• Analyze and identify suspicious FWA activity leveraging knowledge of health care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant policies along with state and federal regulations; follow protocols to identify instances of potential FWA through data analysis using a variety of analytics, systems, tools, and industry resources
• Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation; collaborate and refer non-SIU related issues and activities to external departments (Appeals & Grievances, Networks, Clinical) for handling
• Organize data, document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations
• Other duties as assigned

Skills

• Bachelor's degree in Business, Criminal Justice, Healthcare or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
• Must be eligible to work in the United States without the need for work visa or residency sponsorship
• Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision
• Ability to review and evaluate data and information to identify suspicious patterns
• Strong verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers
• Ability to work cooperatively with others to foster trust and collaboration across the enterprise
• Ability to think critically and solve problems
• Demonstrates an understanding of health care coding conventions, fraud schemes, reimbursement methodologies, policy interpretation, and state and federal regulations
• Basic understanding of Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications
• PBM/health care experience
• Certified Fraud Examiner (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification
• Certified Pharmacy Technician (CPhT)

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