Manager, Special Investigation Unit (SIU) - Pharmacy
About The Position
Develop, implement, and manage strategic fraud, waste, and abuse activities while maintaining state and federal requirements and monitoring trends and schemes. The role monitors business processes and systems to assure integrity and compliance in billing and claims payment, and leads a team investigating possible fraud, waste, and abuse referrals. The position also develops educational materials to address or identify waste activities, attends state and federal meetings as required by specific contracts, reviews post-payment cases with appropriate parties to obtain refunds, prepares and distributes monthly and quarterly savings reports, and participates in Appeals Committee, work groups, and interdepartmental meetings.
Requirements
- Bachelor’s degree in Business, Healthcare, Criminal Justice, a related field, or equivalent experience.
- At least 4 years of combined medical claim investigation, financial impact analysis, business analysis, compliance, or fraud and abuse experience.
- Thorough knowledge of medical terminology.
Nice To Haves
- Previous experience in a managed care environment.
- Previous experience as a lead or supervisor of staff, including hiring, training, assigning work, and managing performance.
- Knowledge of Microsoft Excel, medical coding, claims processing, and data mining.
- Pharmacy or Pharmacy Benefit Manager (PBM) experience, and/or pharmacy technician credentials or experience.
- Certified Pharmacy Technician (CPhT), medical records, or coding license.
Responsibilities
- Develop, implement, and manage strategic fraud, waste, and abuse activities while maintaining state and federal requirements and monitoring trends and schemes.
- Monitor business processes and systems to assure integrity and compliance in billing and claims payment.
- Lead a team investigating possible fraud, waste, and abuse referrals.
- Develop educational materials to address or identify waste activities as requested by the health plan and on an ad-hoc basis.
- Attend state and federal meetings as required by specific contracts.
- Review post-payment cases with appropriate parties to obtain refunds.
- Prepare and distribute monthly and quarterly savings reports.
- Participate in Appeals Committee, work groups, and interdepartmental meetings.
Benefits
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field, or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Manager
