FWA Investigative Analyst--Pharmacy

Mercalis

14h

About The Position

Valeris is a fully integrated life sciences commercialization partner that provides comprehensive solutions that span the entire healthcare value chain. Formed by the merger of PharmaCord and Valeris, Valeris™ revolutionizes the path from life sciences innovation to real-life impact to build a world in which every patient gets the care they need. Valeris works on behalf of life sciences companies to improve the patient experience so that patients can access and adhere to critical medications. Backed by proven industry expertise, a deep commitment to patient care, the latest technology, and exceptionally talented team members, Valeris provides the data and strategic insights, patient support services and healthcare provider engagement tools to help life sciences companies successfully commercialize new products. Valeris provides commercialization solutions to more than 500 life sciences customers and has provided access and affordability support to millions of patients. The company is headquartered in Morrisville, North Carolina and Jeffersonville, Indiana. To learn more about Valeris, please visit www.valeris.com. As an FWA Investigative Analyst-Pharmacy, you will have experience investigating data and trends by pharmacies, patients, and healthcare providers seeking out potential fraud, waste, and/or abuse activity. The selected candidate should demonstrate a clear ability to act upon alerts and data dashboards that have identified potential fraud, waste, and abuse. This role protects the integrity of our copay and voucher assistance programs in the marketplace across Valeris The FWA Investigative Analyst will be responsible for reviewing all client related aspects of monitoring, detection, investigation, and reporting of fraud, waste, or abuse against co-pay and voucher programs to reduce and proactively protect our clients’ programs from suspicious behaviors. The FWA Investigative Analyst will daily analyze suspicious claim activity and other behaviors identified by internal tools and external referrals that will trigger an investigation analysis including, but not limited to, data analysis, online record searches/validations, calls to pharmacies and/or healthcare providers, and work with our internal teams and processors to determine if fraud and/or abuse is occurring.

Requirements

2-5 years’ experience in investigations pharmacy/healthcare FWA.
Bachelor's degree from a 4-year college or university or equivalent level of training and experience.
Demonstrate a strong power of analytical reasoning
Possess knowledge of the pharmaceutical industry and claim data, particularly how claims are processed as well as trends that indicate suspicious activity.
Experience with medical and/pharmacy claim processing, forms, and workflow. Claim billing experience a plus.
Knowledge of MS Excel and Word.
Open to learning Valeris/vendor proprietary software and systems
Must have excellent verbal and written communication skills.
Well organized and able to perform under pressure, ability to prioritize, and plan proactively in a methodical manner
Superior people skills, relationship building, and ability to work with diverse groups of colleagues and clients
Experience presenting to leadership and external business partners, as necessary.

Responsibilities

Investigate cases of potential pharmacy fraud, waste, or abuse that are identified through analytical tools, external referrals, and other sources.
Collect and evaluate potential suspicious patterns in claims data
Develop and deploy the most efficient investigative strategies for each investigation.
Analyze data and trends from claims where Valeris patient assistance programs have been processed that exhibit suspicious behavior.
Manage case reviews, case files, overpayment recoveries, and coordination with other departments to mitigate and remedy FWA (fraud, waste, and abuse).
Communicate timely with assigned client(s) via email and/or telephone on a cadence to be determined by the client.
Participate in monthly, quarterly, and annual business reviews as needed with our clients and internal partners.
Document all investigative and pharmacy and/or healthcare provider outreach activities and correspondence appropriately.
Conduct pharmacy and/or healthcare provider inquiry phone calls to audit and confirm claim data is accurate.
Ensure all internal Standard Operating Procedures (SOP) are followed in a timely manner and stay up to date.
Lead cross functional initiatives to continually examine and enhance processes and technology used to identify and report suspicious claim activity.
Assist in the development of policies and procedures to improve our processes and procedures
Properly control the release of confidential information and maintain confidentiality
Review monthly metrics and prepare reports for internal and external use.
Record and maintain master blocked pharmacy, patient and/or healthcare provider records. Communicate and coordinate any changes to the pharmacy network with our processors.
Create case file with all evidence and its impacts to Valeris programs to be reviewed and approved by Valeris management and Chief Compliance Officer.
Conduct other internal tasks that ensure FWA is proactively identified and researched prior to a full investigation.
Other duties as assigned such as special investigation cases or other initiatives, as necessary.
Utilize Valeris’ values as the driving force behind the team’s success
On time adherence to training deadlines for all corporate policies and procedures
Ensure all SOPs are followed with consistency
Perform additional tasks or projects as assigned

Benefits

Medical, dental, and vision plans, including HSA- and FSA-eligible options, with Valeris contributing toward premium costs
Additional health support, including telehealth and Employee Assistance Program (EAP) services
Company match on Health Savings Account contributions
Free Basic Life and AD&D coverage equal to your annual earnings, with a minimum of $50,000 and a maximum of $300,000
Company-paid Short-Term Disability coverage, with the option to purchase Long-Term Disability
401(k) Retirement Savings Plan with 100% match on the first 5% you contribute, with immediate vesting
Paid Time Off (PTO) and Sick Leave to support work-life balance
Team members receive nine paid holidays plus two floating holidays
Opportunities for advancement in a company that supports personal and professional growth
A challenging, stimulating work environment that encourages new ideas
Work for a company that values diversity and makes deliberate efforts to create an inclusive workplace
A mission-driven, inclusive culture where your work makes a meaningful impact