Manager Special Investigations Unit

Location
Eagan, Minnesota
Salary
Apply for details
Posted
Mar 15, 2019
Role
Manager
Job Type
Long-Term
Hours
Full Time

The Manager of the Special Investigations Unit (SIU) oversees the day to day operations of Prime’s SIU function and provides cross-department leadership for initiatives impacting all SIU teams. This position is accountable for the effective management of the investigation, detection and mitigation efforts related to pharmacy, member, and/or prescriber fraud.  The Manager Special Investigations Unit works in collaboration with leaders throughout the organization, as well as external stakeholders, to prevent, detect and resolve fraud, waste and abuse (FWA).

Responsibilities

  • Provide work direction for the SIU team; develop quantitative and qualitative performance measures and ensure accountability for department objectives and deliverables; proactively evaluate and address objectives that are not being met with staff
  • Prioritize investigation activities within the SIU by evaluating impact, root cause, state and federal regulations, client commitments and risk; collaborate with internal and external stakeholders, including state and federal law enforcement, to ensure timely, but thorough investigation of potential pharmacy fraud
  • Establish a team culture of identifying and implementing process improvements to drive efficiency and innovation; collaborate with key internal functions to implement process and procedural changes in support of FWA priorities or system enhancements to prevent FWA risk
  • Identify key internal and external business contacts to support SIU activity; establish an appropriate communication and collaboration cadence to ensure the appropriate parties are engaged when required
  • Develop and oversee investigative resolution procedures, including but not limited to corrective action plans, terminations, appeals, recoveries, negotiations, mediation, and litigation
  • Coach SIU employees on effective and thorough investigative case management and presentation; develop measures and methods for professional development
  • Evaluate industry trends and establish fraud identification and prevention metrics, practices and policies
  • Collaborate with clients, regulatory, and law enforcement agencies to coordinate SIU activity; serve as representative for Prime’s SIU function in partnership with Legal team
  • Develop and maintain in-depth knowledge of the company's business, industry and regulatory environments; routinely conduct regulatory analysis and review new guidelines received from government agencies; adjust processes or practices as required
  • Other duties as assigned

Minimum Qualifications

  • Bachelors degree in Criminal Justice, Healthcare, or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
  • 5 years combined experience in healthcare, investigation, audit, or other highly regulated industry
  • 3 years of progressive leadership responsibility
  • Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications

  • Extensive experience in health care, legal, audit, claims and/or investigative services
  • Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need
  • Ability to think critically, problem solve and make decisions while anticipating the broad impact of decisions
  • Ability to establish trust, respect and credibility and form close working relationships with individuals at all levels of an organization; collaborates effectively cross-functionally and with clients and other external partners
  • Demonstrated ability to distill complex concepts or situations into concise and compelling communications
  • Expert communication, negotiation and influencing skills
  • Proven ability to maintain discretion and confidentiality

Preferred Qualifications

  • Solid understanding of claims processing
  • Expert understanding of point of sale and on-line pharmacy claims processing environments
  • Licensed Pharmacist or Certified Pharmacy Technician (CPhT)

Minimum Physical Job Requirements

  • Ability to travel up to 10% of the time
  • 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 Director Special Investigations Unit in the Pharmacy Audit and FWA department

 

 

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions.

 

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