Fraud and Waste Investigator

Profile

Description

The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Fraud and Waste Professional 2 coordinates and collaborates with multiple areas of HPS to identify trends and review claims analysis for potential FWA, accuracy, contract interpretation, and compliance with policies and procedures. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications


Pharmacy Technician Certification, with 1-3 years experience working in a pharmacy setting (Retail, Clinical, Mail Order, Specialty, etc.)
Strong understanding of pharmacy/healthcare claims, & knowledge of healthcare payment methodologies
At least 2 years of Pharmacy FWA investigations and/or auditing experience
Excellent verbal and written communication skills necessary to present information to management & other cross functional areas.
Comprehensive knowledge of Microsoft Office applications, specifically Excel for data analysis and reporting
Inquisitive nature; think outside the box attitude
Ability to self-motivate & work independently, with the ability to comprehend & analyze data to metrics, to solve problems
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Demonstrated ability to manage multiple task and meet deadlines, and follow in a timely manner
Ability to travel up to 15% - conferences, team meetings


Preferred Qualifications


Bachelor's degree
CFE and/or AHFI Certifications
Understanding of healthcare industry, claims processing and investigative process development.
Experience in a corporate environment and understanding of business operations


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Scheduled Weekly Hours

40

Company info

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