Investigator II, SIU

Navitus Health Solutions, LLC•,

2d•$63,827 - $76,900•Remote

About The Position

Due to growth, we are adding a Investigator II, SIU to our team. The Investigator II, SIU assists the Sr. Manager, Compliance and SIU in the development, maintenance and execution, and continuous improvement of the organization’s Fraud, Waste, and Abuse program, controls, and associated policies and procedures. The position independently conducts complex investigations involving pharmacy claims, prescribers, pharmacies, members, providers, and other entities, using advanced investigative techniques, claims analysis, and sound professional judgment. The Investigator II evaluates allegations and data, develops investigative strategies, documents findings, recommends appropriate actions, and communicates investigation results to internal stakeholders and clients. Investigations must be completed promptly, accurately, professionally, and discreetly within applicable legal, regulatory, contractual, and organizational requirements.

Requirements

Bachelor’s degree, preferably in criminal justice, healthcare administration, pharmacy, accounting, finance, data analytics, risk management, compliance, or a related field, or equivalent work experience, required.
Certified Fraud Examiner, Accredited Health Care Fraud Investigator, or equivalent certification required.
4 years’ experience in pharmacy and/or healthcare claims investigations required.
Participate in, adhere to, and support compliance program objectives.
The ability to consistently interact cooperatively and respectfully with other employees.

Nice To Haves

Pharmacy Technician certification preferred.
Pharmacy auditing and/or working with a Special Investigation Unit or similar relevant investigative experience preferred.
Knowledge of Medicare and Medicaid billing and third-party payer billing regulations, program integrity, program requirements, and/or reimbursement preferred.

Responsibilities

Assist with the development and maintenance of the Navitus fraud and abuse program controls and guidance.
Conduct complex FWA investigations involving pharmacy claims, prescribers, pharmacies, members, providers, and other individuals or entities, including matters involvingsuspected deception, misrepresentation, inappropriate billing, or concealment made by an individual or entity knowing that the deception could result in some unauthorized benefits to the individual, entity, or some other party.
Independently plan and execute investigative activities, including allegation assessment, lead development, claims and data analysis, evidence review, interviews or information gathering, findings development, documentation, escalation, and recommended action.
Apply advanced knowledge of pharmacy claims, billing, reimbursement, data mining, investigative processes, and applicable Medicare, Medicaid, commercial, and other third-party payer requirements when evaluating potential FWA.
Support recurring client SIU meetings, including agenda preparation, case-status review, trend discussion, investigation summaries, responses to client questions, follow-up activities, and coordination with account management and operational stakeholders.
Support delegation audits, tracer audits, program audits, and regulatory reviews, including questionnaires, evidence packages, case narratives, selected-incident walkthroughs, findings analysis, corrective actions, root-cause information, implementation timelines, and preventive controls.
In cooperation with other departments, identify areas of risk exposure and work to develop, document, implement, and monitor preventive and detective proceduresprocedures to prevent, detect and address fraud.
Recommend and implement process improvements based on investigative findings, recurring trends, audit results, control gaps, operational observations, and lessons learned
Conduct and/or support fraud training for associates, clients, contractors, and other stakeholders, as appropriate.
Develop and document accurate, complete, and timely investigation reports, client recommendations, corrective-action summaries, recovery documentation, client deliverables, departmental reports, credentialing recommendations, case-status updates, and other investigative work products.
Other duties as assigned.