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Job Posting Title

Associate Pharmacy Claims FWA Analyst - Remote

Job Description

The Associate Fraud, Waste and Abuse (FWA) Analyst will support the assigned business area in triaging potential cases to Prime’s Pharmacy Audit and Special Investigation Unit (SIU) operations team. During the process this role is expected to research, analyze, and compile supporting information. This role will also support FWA projects and practices in identifying FWA trends and schemes.

Responsibilities

• Research and collect information to aid in the identification of FWA trends

• Support triage of suspected FWA leads to appropriate business area along with compiled research and data meeting established triage efficacy rate while tracking all activity and data quality to support operational and performance reporting

• Adhere to business processes of assigned business area and share enhancement or improvement recommendations that impact fraud case selection in collaboration with other team members to assist in the development and implementation of new or enhanced practices

• Follow protocols to identify instances of potential FWA through data analysis using a variety of analytics, systems tools, and industry resources

• Leverage knowledge of heath care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant policies along with state and federal regulations to identify suspicious FWA activity

• Support Prime’s Fraud Tip Hotline by regularly logging hotline reports, triaging to the appropriate business area, and escalating to senior team members when appropriate while ensuring hotline reports are triaged within the pre-defined timeline

• Other duties as assigned

Minimum Qualifications

• Associate’s degree in Business, Criminal Justice, Health Information Management or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required

• 1 year of work experience in fraud investigation, analytics audit, or pharmacy/medical billing

• Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications

• Ability to communicate and present data effectively

• Demonstrates an ability to work cooperatively with others; fosters trust and collaboration across the enterprise

• Ability to think critically and problem solve

• Intermediate proficiency with MS Office suites such as Access, Excel, PowerPoint, and Word

• Demonstrates an understanding of health care coding conventions, fraud schemes, reimbursement methodologies and state and federal regulations

Preferred Qualifications

• PBM/health care experience

• Experience with SAS or SQL

• Certified Fraud Examiners (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification

Minimum Physical Job Requirements

• Constantly required to sit, use hands to handle or feel, talk and hear

• Frequently required to reach with hands and arms

• Occasionally required to stand, walk and stoop, kneel, and crouch

• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure

• Reports to Manager in the Pharmacy Audit and FWA department

Potential pay for this position ranges from $22.45 - $31.78 based on experience and skills. Pay range may vary by 8% depending on applicant location.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (https://www.primetherapeutics.com/careers/benefits/) and click on the "Benefits at a glance" button for more detail.

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, genetic information, marital status, family status, national origin, age, disability, veteran status, or any other legally protected class under federal, state, or local law.

Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.

If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. ​ If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at 1.866.469.1257 or email Careers@primetherapeutics.com.