Investigator I, SIU-Remote

Putting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new

We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

The Investigator I, SIU will assist the Sr. Manager, Compliance and SIU and SIU Investigators in the execution and maintenance of the Navitus fraud, waste and abuse program, including controls, policies & procedures, communications and training. The Investigator I will work in a semi-professional role with an intermediate level of independence, to ensure case referrals are investigated, SIU program elements are implemented and controls are examined periodically for effectiveness and efficiency. The Investigator I will work closely with the investigators and serve in a back-up role to the investigators for projects that involve fraud detection, reporting and recommendations. The role requires knowledge of investigative processes, data mining and claims review, ability to read and understand regulations and have general knowledge of pharmacy. The Investigator I shall have the ability to be self-initiating for projects, seeking supervisory guidance where appropriate. The Investigator I will periodically receive direction and oversight of work from the Investigator II.

Is this you? Find out more below!

How do I make an impact on my team?

• Assist SIU team in the development, execution and maintenance of the Navitus fraud and abuse program, including controls and guidance.
• Independently investigate cases of potential abuse in accordance with the investigation protocols and procedures, including final analyses.
• Under the direction of an SIU Investigator, proactively identify potential FWA fraud schemes, and investigate fraudulent activities where there is intentional deception, misrepresentation, or concealment made by an individual or entity knowing that the deception could result in some unauthorized benefits to the individual, the entity, or some other party.
• Under the direction and guidance of the SIU team, analyze claims data for cases and/or potential fraudulent activities identified by Plan Sponsors, including reports such as the CMS high risk report, received through HPMS alerts, or from law enforcement.
• Periodically provides updates on certain FWA activities to the FWA Committee.
• Identify risks and develop resolution for the controls and compliance with the exclusion review process. Controls shall include the revision of policies and procedures, use of external resources, in-depth knowledge of all exclusion requirements and regulations; and awareness of internal systems.
• Assist in the development of FWA training for new employees, annual re-training and supplemental training including preparation of training materials, tracking training activities, and analyzing training results for process improvement opportunities.
• Actively participate in webinars, local, state and national organizations and events focused on fraud prevention and detection for the purpose of ongoing learning, knowledge of industry best practices and identification of fraud schemes, as may be budgeted and available.
• Under the guidance of the SIU team, create trending and metrics reports related to FWA data.
• Identify SIU processes that can be improved and suggest ways to improve, including collaboration with other departments, as necessary. Suggest plans of action to achieve those process improvements. Lead efforts to implement the improvements, where applicable.

What our team expects from you?

• A bachelor’s degree, preferably in criminal justice, risk management, healthcare and/or pharmacy preferred. A combination of education and relevant work experience may substitute the education requirement. Pharmacy Technician certification strongly desired
• A minimum of two (2) years’ experience in pharmacy and/or healthcare claims investigations and/or auditing with a Special Investigation Unit or similar relevant investigative experience is highly desired.
• Knowledge of Medicare and Medicaid billing and third-party payer billing regulations and reimbursement is also highly desired.
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Hours/Location: Monday-Friday 8:00am-5:00pm, CST-Remote
• Paid Volunteer Hours
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
• Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Nine paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program