Principal Investigator Pharmacy - Dallas and Houston, TX

Primary Responsibilities

• Assess complaints of alleged misconduct received within the Company
• Investigate highly complex cases of fraud, waste, and abuse
• Detect fraudulent activity by members, providers, employees, and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current, and thorough case information in the Special Investigations Unit's (SIU's) case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the latter
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators
• Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings
• Communicate effectively, including written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities

Required Qualifications

• Associate's degree
• 3+ years of experience in fraud, waste and abuse (FWA) investigations/auditing
• 3+ years of experience with state/federal laws and regulations pertaining to healthcare FWA
• 3+ years of experience in analyzing data to identify fraud, waste and abuse trends
• Ability to participate in legal proceedings, arbitration, and depositions in the direction of management
• Demonstrate advanced level of proficiency in Microsoft Excel and Word
• Demonstrate advanced level of knowledge in pharmacy claims processing
• Reside within Dallas and Houston, TX or surrounding areas, with the ability to travel up to 50% in the Dallas and Houston, TX area
• Access to reliable transportation and valid US driver's license

Preferred Qualifications

• Specialized knowledge/training in healthcare FWA investigations
• Active affiliations with the National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Licenses and/or Certified Pharmacy Technician (CPhT)
• Operational experience with a pharmacy and/or pharmacy benefit manager (PBM)