Senior Pharmacy SIU Investigator

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Take the initiative to lead intricate investigations into fraud, waste, and abuse involving providers, members, pharmacies, vendors, and other entities.

• Utilize referrals, claims data, medical records, interviews, analytics, and various investigative resources to construct cases.

• Examine claims, billing patterns, medical records, provider documentation, financial data, and other forms of evidence.

• Formulate investigative strategies, set case direction, and oversee investigations until resolution.

• Draft investigative reports, referrals, case summaries, presentations, and pertinent documentation.

• Offer subject matter expertise to investigative teams regarding techniques, case development, documentation, evidence, and regulations.

• Collaborate with Compliance, Legal, Payment Integrity, Provider Relations, government agencies, and law enforcement partners.

• Detect emerging fraud schemes, billing inconsistencies, control deficiencies, and program integrity threats.

• Propose improvements to investigative processes, monitoring activities, and analytical methodologies.

• Assist in audits, overpayment identification and recovery, regulatory responses, special projects, and enterprise initiatives.

• Ensure investigations comply with quality standards, timeliness, documentation, service-level expectations, and regulatory requirements.

• Contribute to training, knowledge sharing, and continuous improvement efforts.

• Facilitate case advancement through onsite audits, visits, drive-by activities, and interviews with members, providers, and witnesses.

• Undertake additional responsibilities as assigned and adhere to established policies and standards.

⛳️ Requirements

• A Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent experience is required.

• A minimum of 4 years' experience in conducting fraud, waste, and abuse investigations, healthcare fraud investigations, claims audits, payment integrity reviews, healthcare compliance investigations, law enforcement investigations, or similar investigative roles.

• Proven experience in leading complex investigations that involve multiple data sources, extensive analysis, and coordination with internal and external stakeholders.

• Skilled in preparing investigative reports, referrals, presentations, and supporting documentation for leadership, regulatory agencies, and law enforcement entities.

• Familiarity with interpreting and applying federal and state healthcare regulations, including Medicaid, Medicare, and other government-sponsored healthcare programs is preferred.

• Possession of certifications such as Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or related investigative, auditing, or compliance credentials is preferred.

• Additional qualifications may be necessary to meet federal, state, regulatory, contractual, or program-specific requirements.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K and stock purchase plans available.

• Tuition reimbursement options.

• Paid time off in addition to holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.

• Additional incentive programs may be part of the overall compensation package.

• An equal opportunity employer dedicated to diversity.