Pharmacy Fraud Investigator-Express Scripts-Remote

The Pharmacy Fraud Investigator identifies fraud and abuse at suspected pharmacies by using existing investigation techniques that include internet research and written and verbal outreach to members, physicians, suppliers, and pharmacies. The individual in this role uses critical thinking skills to develop additional investigation process steps and techniques to supplement and enhance current processes. Works closely with and develops relationships with internal stakeholders and law enforcement including but not limited to account managers, client SIU units, MEDIC, and DOH Investigators. Collaborates with internal SIU unit analytics team to asses and identify potential fraud scenarios for future investigation based on historical case results. Assists in mentoring and developing Program Integrity team members. ESSENTIAL FUNCTIONS

• Identify and perform special projects.
• Identify and investigate cases of suspected fraud and abuse for assigned clients.
• Analyze and evaluate potential fraud and abuse situations using corroboratory information obtained by correspondence with members, physicians, and pharmacies.
• Prepare formal and thorough written reports to upper management, clients, and the Medicare Drug Integrity Contractors (MEDIC) expressing the findings of completed investigations.
• Prepare for and take lead role in client communications, including conference calls and on-site meetings, to present status updates of ongoing issues, results of completed investigations, etc., for assigned clients.
• Develop these cases in compliance with any applicable policies, procedures, or regulatory requirements.

QUALIFICATIONS:

• Ability to work well with senior management and high level external contacts, handle sensitive or confidential information is critical, work with minimum management oversight on multiple projects with competing priorities.
• Minimum 3 years' experience in health insurance investigation and or pharmacy/audit strongly preferred
• Experience with Microsoft products strongly preferred (Excel, Access, Word)
• Strong communication skills, both written and oral, are required
• Must be able to adapt to changing priorities

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 63,700 - 106,100 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.