Pharmacy Investigator Lead

Location: Atlanta GA, Richmond VA, Costa Mesa CA, Indianapolis IN

Hours: Standard Working hours

Travel: This role requires associates to be in-office 1 – 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy такую hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Responsible for providing leadership and guidance to the Special Investigations Unit Pharmacy team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Provides comprehensive sound judgment in the application of various investigative methodologies to team members能提现吗 and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating Fraud, Waste and Abuse within the healthcare industry.

• Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit for pharmacy Investigations; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day‑to‑day operations as assigned by management.
• Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers.
• Prepares statistical/financial analyses and reports to document findings and maintains up‑to‑date case files for management review.
• report and notification of findings letter suitable for distribution to providers and legal counsel.
• Creates and presents settlement offers for provider issues(macron) for review and approval by management and/or legal.
• Communicates orally and in writing with all customers, internal and external, regarding findings.
• Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets.
• Prepares and delivers training to internal and external entities.
• Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.
• Represents the Company in court proceedings regarding research findings.
• Provides guidance to investigators and other SIU staff in the development of criminal and recovery cases.
• Leads SIU projects or initiatives.

• Requires a BA/BS and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of Brux and experience, which would provide an equivalent background.

• Pharm
  
  D or CPhT strongly preferred.
• Knowledge and experience working with Pharmacy Benefit Managers and Pharmacy programs strongly preferred.
• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD, or other job related designation preferred.
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

For candidates working in person or virtually in the below location(s), the salary
* range for this specific position is $87,280 to $150,558

Location:

California

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any…