Pharmacy FWA Investigator I

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Pharmacy FWA Investigator - Pharmacy Fraud, Waste and Abuse (Previous or current Pharmacy Technician with Excel, claims analysis and data analysis)

Position Purpose: Investigates allegations pertaining to Pharmacy Fraud, Waste and Abuse and develops strategies to effectively research specific FWA schemes. Recommends effective remedial actions of a pharmacy (e.g., pharmacy network termination; corrective action plans) when a credible allegation of fraud exists. Proactively analyzes pharmacy claims and other available data sources to identify FWA schemes.

• Investigates allegations pertaining to Pharmacy Fraud, Waste and Abuse and develops strategies to effectively research specific FWA schemes.

• Prepares and submits evidentiary documents and prepares cases for presentation to the Pharmacy Network Review Committee (PNRC).

• Accurately documents investigations and aggregates data for internal reporting of outcomes and recoveries.

• Prepares cases for referral to appropriate parties as determined by the evidence and regulatory requirements.

• Proactively analyzes pharmacy claims and other available sources of data to identify FWA schemes and aberrant activity to generate pharmacy leads.

• Recommends effective remedial actions of a pharmacy (e.g., pharmacy network termination; corrective action plans) when a credible allegation of fraud exists.

Education/Experience:

• Associate’s degree in a related field or equivalent combination of experience.

• Pharmacy Technician or Pharmacy Coordinator (i.e. hospital and/or retail environments or related experience with a Health Plan or Pharmacy Benefit Manager).

• Preferred - 2+ years of experience in pharmacy claims auditing and/or pharmacy investigations

• Preferred -- Previous experience with pharmacy government programs such as Medicare and Medicaid

License/Certification:

• Preferred - Certified Pharmacy Technician (CPhT)

• Preferred - Accredited Health Care Fraud Investigator (AHFI)

Additional job specific details and skills:

• Proficiency with Excel and databases

• Analytical skills - Data analysis, claims analysis and reports with large volumes of claims

• Thrives on data analysis and frequent change in direction

• Experience utilizing strategies to improve processes

• Exceptional critical thinking skills

• Strong decision making and problem-solving skills

• Good organization and time-management skills

• FWA or audit experience, highly preferred

• Experience in Retail Pharmacy, highly preferred

Working shift: 8am - 5pm or 8:30am - 5pm Monday - Friday (Eastern / EST)

Please attach an up-to-date resume that meets the requirements above to your application

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