|Location: Lee’s Summit, MO
Pharmacist Investigator will be responsible to develop, oversee, and evaluate fraud, waste, and abuse processes and programs related to the pharmacy plan. Reviews pharmacy claim data from our anti-fraud software program, FICO, in order to detect inappropriate billing and/or potential fraud, waste or abuse. Conducts effective preliminary investigations of pharmacy FWA referrals. Gathers sufficient evidence from pharmacy data and claims data to effectively evaluate an allegation of pharmacy FWA. Documents investigations, including preliminary and final case reports, for both internal tracking and OPM OIG notifications. Coordinates FWA investigations with the PBM and OPM OIG, to include course of action notifications from the PBM. Responsible for assuring that data received from PBM is accurate in response to data requests from OPM OIG. Will be available for consultations as requested by an OPM OIG agent. Will be responsible for coordinating results related to PBM savings and data for the OPM annual FWA report. Working with the SIU team and PBM to resolve inappropriately processed claims to include overpayment recoveries. Assist with providing training to SIU staff and GEHA workforce.
• Develops, oversees and evaluates the fraud, waste and abuse processes and programs related to the pharmacy benefits/plan.
• Works closely with PBM to assure processes are in place to share information and data on fraud, waste and abuse issues and reporting guidelines for OPM annual report.
• Utilizes anti-fraud software to detect pharmacy fraud. Researches leads from the software, using pharmacy knowledge and claims history, medical and pharmacy.
• Develops notifications to be submitted to OPM OIG from software leads, internal sources, PBM reports, etc.
• Documents investigative steps and evidence in SIU case tracking system.
• Creates policies and procedures for SIU staff to follow on pharmacy fraud investigations. Will be responsible for updating SIU manual to include information on pharmacy investigations.
• Will receive all course of action reports from PBM and investigate the possible fraud issues and possible OIG notifications.
• Work with PBM on a quarterly basis to assure that the data gathered is accurate for the OPM report. Will verify that data is sufficient to be in compliance with the reporting requirements.
• OPM OIG agents may request consultations on pharmacy issues and this position will be available for those consultations and to provide professional advice on the investigations.
• Work with SIU staff to create overpayments both on pharmacy side but also on medical side related to fraud in pharmacy benefit payments.
• Will be resource for SIU on pharmacy and drug interactions questions. Assist SIU with company workforce FWA training.
• Requires a PharmD degree from an ACPE-accredited School of Pharmacy
• Candidate must be licensed, or eligible for licensure, within the state of Missouri
• 3 years of managed care experience, or completion of a PGY-1/PGY-2 residency with a managed care focus preferred.
• Must possess knowledge or skillset that qualify them for a special investigation position.
• Must have a strong commitment to identifying and rectifying health plan fraud, waste and abuse.
• Exemplary interpersonal, communication and organizational skills.
• Excellent oral and written communication skills.
• Will be required to attend FWA training and obtain accreditation as a health care fraud investigator within 3 years of being in the position.
GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant.
Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.