Pharmacy Investigator Lead

Elevance Health • Costa Mesa, CA

1d • $87,280 - $150,558 • Hybrid

About The Position

Responsible for providing leadership and guidance to the Special Investigations Unit Pharmacy team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Provides comprehensive sound judgment in the application of various investigative methodologies to team members and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating Fraud, Waste and Abuse within the healthcare industry.

Requirements

• Requires a BA/BS and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

• PharmD or CPhT strongly preferred
• Knowledge and experience working with Pharmacy Benefit Managers and Pharmacy programs strongly preferred
• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred

Responsibilities

• Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit for pharmacy Investigations; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day-to-day operations as assigned by management
• Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers
• Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review
• Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel
• Creates and presents settlement offers for provider issues for review and approval by management and/or legal
• Communicates orally and in writing with all customers, internal and external, regarding findings
• Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets
• Prepares and delivers training to internal and external entities
• Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts
• Represents the Company in court proceedings regarding research findings
• Provides guidance to investigators and other SIU staff in the development of criminal and recovery cases
• Leads SIU projects or initiatives

Benefits

• Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees