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Role Description
The Associate SIU Specialist is responsible for the intake and initial handling of allegations of fraud, waste or abuse (FWA). This role conducts preliminary investigations to assess the merit of an allegation through fact gathering and analysis of data and recommends appropriate action. It also serves as a corporate resource on FWA issues and maintains confidentiality and compliance with HIPAA privacy requirements and applicable state and federal regulations.
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Intake and maintain caseload of FWA incidents/allegations; prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements
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Analyze and identify suspicious FWA activity leveraging knowledge of health care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant policies along with state and federal regulations; follow protocols to identify instances of potential FWA through data analysis using a variety of analytics, systems, tools, and industry resources
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Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation; collaborate and refer non-SIU related issues and activities to external departments (Appeals & Grievances, Networks, Clinical) for handling
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Organize data, document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations
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Other duties as assigned
Qualifications
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Bachelor’s degree in Business, Criminal Justice, Healthcare or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
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May have no prior experience
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Must be eligible to work in the United States without the need for work visa or residency sponsorship
Requirements
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Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision
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Ability to review and evaluate data and information to identify suspicious patterns
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Strong verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers
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Ability to work cooperatively with others to foster trust and collaboration across the enterprise
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Ability to think critically and solve problems
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Demonstrates an understanding of health care coding conventions, fraud schemes, reimbursement methodologies, policy interpretation, and state and federal regulations
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Basic understanding of Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications
Preferred Qualifications
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PBM/health care experience
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Certified Fraud Examiner (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification
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Certified Pharmacy Technician (CPhT)
Compensation
Potential pay for this position ranges from $21.15 - $31.73 based on experience and skills.
Company Description
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
