Senior Investigator jobs at PacificSource Health Plans

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. Please note: Candidate must reside within the state of Kentucky Position Purpose: Position acts as a subject matter expert for the Contractor's Program Integrity unit to reduce Fraud, Waste and Abuse of Medicaid services within Kentucky. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics. Serve as the single point of contact with the Department Facilitate timely response to Department requests for information Serve as a lead for the Kentucky market Manage and coordinate cases being investigated by the SIU Maintain all vendor cases Assist with conducting complex investigations, including on-site investigations, review, complete and submit FWA referrals to the state as needed Maintain and approve all reports submitted to the state Monitor state contract and regulatory changes that may arise Works quickly, with great attention to detail, while managing competing priorities. Logs, tracks, resolves and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and WellCare Corporate guidelines in which special care is required to protect and enhance WellCare's reputation. Works cross-functionally in preparation of effective communications with stakeholders on social channels and provides content to appropriately respond to social media posts regarding provider inquires. Tracks & trends issues that result in AHCA complaints for purposes of developing preventive measures Escalates customer service questions to other appropriate internal teams as needed. Supports the provider escalation project team to resolve claims and payment issues. Identifies root-cause issues to ensure enterprise solutions and communicate findings as needed. Shares case studies and best practices throughout the enterprise. Contributes to the creation of documentation such as SOP's, FAQ's, and resources to be used by internal customer service agents. Researches escalated issues and takes appropriate action to resolve them within established service level agreements, WellCare best practice and quality standards. Applies a comprehensive knowledge of claims processing, provider customer service and payment knowledge to escalated provider inquiries. Education/Experience: Bachelor's degree in related field or Associate's degree with 6 years of applicable experience, or a High School/GED with 7 years of applicable experience may substitute for the Bachelors Degree . 5+ years of management experience Investigations and healthcare fraud-related investigations with audit and risk analysis. 1+ year of experience in managed care or health insurance company. Candidate Skills: In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes. Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources. Ability to work in a fast paced environment with changing priorities. Intermediate Excel, Outlook, PowerPoint, Word, Xcelys, SalesForce, and Microsoft Access. Knowledge and understanding of managed care claims processing systems and medical claims coding preferred Licenses and Certifications: A license in one of the following is required: Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE). Other Pharmacy Investigator - Certified Pharmacy Technician. Pay Range: $68,700.00 - $123,700.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. We are currently hiring for multiple positions. Candidates for these role must reside in one of the following states: CA, HI, IL, NE, and OH. Position Purpose: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Conduct investigations of potential waste, abuse, and fraud Document activity on each case and refer issues to the appropriate party Perform data mining and analysis to detect aberrancies and outliers in claims Develop new queries and reports to detect potential waste, abuse, and fraud Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions Assist with complex allegations of healthcare fraud Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies Complete various special projects and audits Performs other duties as assigned Complies with all policies and standards Education/Experience: Bachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 1+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience. Pay Range: $55,100.00 - $99,000.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start **Caring. Connecting. Growing together.** The **Senior** **Investigator** is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator is responsible for conducting investigations which may include field work to perform interviews and obtain records and/or other relevant documentation. **Schedule:** Monday-Friday Standard Business Hours. You'll enjoy the flexibility to telecommute* from anywhere within the state of **Kentucky** as you take on some tough challenges. **Primary Responsibilities:** + Assess complaints of alleged misconduct received within the company + Investigate medium to highly complex cases of fraud, waste and abuse + Detecting fraudulent activity by members, providers, employees and other parties against the company + Develop and deploy the most effective and efficient investigative strategy for each investigation + Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tracking system + Collect and secure documentation or evidence and prepare summaries of the findings + Participate in settlement negotiations and/or produce investigative materials in support of the latter + Communicate effectively, including written and verbal forms of communication + Develop goals and objectives, track progress and adapt to changing priorities + Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals + Ensure compliance of applicable federal/state regulations or contractual obligations + Report suspected fraud, waste and abuse to appropriate federal or state government regulators + Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership + Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings **What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:** + Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays + Medical Plan options along with participation in a Health Spending Account or a Health Saving account + Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage + 401(k) Savings Plan, Employee Stock Purchase Plan + Education Reimbursement + Employee Discounts + Employee Assistance Program + Employee Referral Bonus Program + Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) + More information can be downloaded at: ************************* You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Bachelor's degree OR associate's degree with 3+ years of equivalent work experience and healthcare related employment + 3+ years of experience in healthcare fraud, waste and abuse (FWA) + 2+ years of experience in state or federal regulatory FWA requirements + 2+ years of experience in analyzing data to identify fraud, waste and abuse trends + Intermediate level of proficiency in Microsoft Excel and Word + Ability to travellocally (in-state) up to 25% of the time, as needed + Ability to participate in legal proceedings, arbitration and depositions at the direction of management + Access to reliable transportation & valid US driver's license + Reside in the state of Kentucky **Preferred Qualifications:** + Demonstrated an intermediate level of knowledge in health care policies, procedures and documentation standards or 2-5 years of experience + Demonstrated intermediate level of skills in developing investigative strategies or 2-5 years of experience + Specialized knowledge/training in healthcare FWA investigations + National Health Care Anti-Fraud Association (NHCAA) + Accredited Health Care Fraud Investigator (AHFI) + Certified Fraud Examiner (CFE) *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._ \#RPO #GREEN

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Special Investigations Unit (SIU) Investigator - Remote **Job Description** The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies. **Responsibilities** + Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholder + Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information + Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process + Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures + Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required + 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy + Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions + Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders + Ability to distill complex concepts or situations into concise and compelling communications + Knowledge and understanding of pharmacy and medical claims processing environment **Preferred Qualifications** + Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) + National Pharmacy Technician Certification through PTCB or ExCPT (CPhT) + Licensed Practical Nurse (LPN) or Registered Nurse (RN) + Experience working with RxClaims and/or JUDI + Previous audit and investigation experience + Pharmacy background within retail, mail order, hospital, or compounding setting + Data mining experience + Excel experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _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._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

National General is a part of The Allstate Corporation, which means we have the same innovative drive that keeps us a step ahead of our customers' evolving needs. We offer home, auto and accident and health insurance, as well as other specialty niche insurance products, through a large network of independent insurance agents, as well as directly to consumers. Job Description This job is responsible for investigating and analyzing complex, multi-discipline coverage and claims that have been referred to the special investigation unit (SIU) for potential fraud. This role typically handles a combination of complex attorney represented and unrepresented claims and moderate to complex losses, in which suspicious activity has been identified. The individual performs a thorough investigation including; (1) conducting background searches, scene investigations, and clinic inspections; (2) taking recorded statements; (3) reviewing and analyzing medical notes, bills, and property damage; and (4) conducting witness interviews and social media searches. The individual conducts surveillance on property and/or creates scene reconstructions on some investigations and reviews whether fraud can be substantiated and supports a lawsuit. The individual provides work guidance and direction to less senior employees and provides mentoring and coaching to the team.**We're seeking an experienced SIU Field Investigator to join our Special Investigations Unit (SIU) in New York! This is a field-based, location-specific position, and the ideal candidate will reside in or near Nassau County, Suffolk County, Brooklyn, Queens, or the surrounding areas.The Investigator will be responsible for conducting in-depth field investigations into auto insurance claims referred to SIU for potential fraud. Property claims experience is a plus. The ideal candidate will have prior investigative experience, strong attention to detail, and the ability to follow structured procedures and documentation standards. Estimating experience is also a plus.This role also requires excellent organizational skills, independent decision-making, and being comfortable navigating challenging conversations and high-pressure situations.**Key Responsibilities • Reviews investigations with fraud outcomes to validate whether denial is appropriate • Conducts complex site inspections, including body shops, medical clinics, loss locations etc. • Conducts complex online data application searches, research, and evaluation • Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads • Enters SIU claim data information into multiple SIU systems • Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement • Conducts thorough investigations of complex that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed • Utilizes analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages • Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process • Researches and responds to complex customer communications, concerns, conflicts or issues Supervisory Responsibilities • This job does not have supervisory duties. #LI-TR1 Compensation Base compensation offered for this role is: SIU Cons I: $55,500- $75,902.64 SIU Cons II: $57,500 - $84,491.18 SIU Sr Cons I: $62,800- $97,165.79 And is based on experience and qualifications. Total compensation for this role is comprised of several factors, including the base compensation outlined above, plus incentive pay (i.e. commission, bonus, etc.) if applicable for the role. Joining our team isn't just a job - it's an opportunity. One that takes your skills and pushes them to the next level. One that encourages you to challenge the status quo. One where you can shape the future of protection while supporting causes that mean the most to you. Joining our team means being part of something bigger - a winning team making a meaningful impact. Effective July 1, 2014, under Indiana House Enrolled Act (HEA) 1242, it is against public policy of the State of Indiana and a discriminatory practice for an employer to discriminate against a prospective employee on the basis of status as a veteran by refusing to employ an applicant on the basis that they are a veteran of the armed forces of the United States, a member of the Indiana National Guard or a member of a reserve component. For jobs in San Francisco, please click “here” for information regarding the San Francisco Fair Chance Ordinance. For jobs in Los Angeles, please click “here” for information regarding the Los Angeles Fair Chance Initiative for Hiring Ordinance. To view the “EEO Know Your Rights” poster click “here”. This poster provides information concerning the laws and procedures for filing complaints of violations of the laws with the Office of Federal Contract Compliance Programs. To view the FMLA poster, click “here”. This poster summarizing the major provisions of the Family and Medical Leave Act (FMLA) and telling employees how to file a complaint. It is the Company's policy to employ the best qualified individuals available for all jobs. Therefore, any discriminatory action taken on account of an employee's ancestry, age, color, disability, genetic information, gender, gender identity, gender expression, sexual and reproductive health decision, marital status, medical condition, military or veteran status, national origin, race (include traits historically associated with race, including, but not limited to, hair texture and protective hairstyles), religion (including religious dress), sex, or sexual orientation that adversely affects an employee's terms or conditions of employment is prohibited. This policy applies to all aspects of the employment relationship, including, but not limited to, hiring, training, salary administration, promotion, job assignment, benefits, discipline, and separation of employment. National General Holdings Corp., a member of the Allstate family of companies, is headquartered in New York City. National General traces its roots to 1939, has a financial strength rating of A- (excellent) from A.M. Best, and provides personal and commercial automobile, homeowners, umbrella, recreational vehicle, motorcycle, supplemental health, and other niche insurance products. We are a specialty personal lines insurance holding company. Through our subsidiaries, we provide a variety of insurance products, including personal and commercial automobile, homeowners, umbrella, recreational vehicle, supplemental health, lender-placed and other niche insurance products. Companies & Partners Direct General Auto & Life, Personal Express Insurance, Century-National Insurance, ABC Insurance Agencies, NatGen Preferred, NatGen Premier, Seattle Specialty, National General Lender Services, ARS, RAC Insurance Partners, Mountain Valley Indemnity, New Jersey Skylands, Adirondack Insurance Exchange, VelaPoint, Quotit, HealthCompare, AHCP, NHIC, Healthcare Solutions Team, North Star Marketing, Euro Accident. Benefits National General Holdings Corp. is an Equal Opportunity (EO) employer - Veterans/Disabled and other protected categories. All qualified applicants will receive consideration for employment regardless of any characteristic protected by law. Candidates must possess authorization to work in the United States, as it is not our practice to sponsor individuals for work visas. In the event you need assistance or accommodation in completing your online application, please contact NGIC main office by phone at **************.

DEA AFISS 2 JOB DESCRIPTION

DEA AFISS 2 JOB DESCRIPTION Senior Financial Investigator (SFI) and Financial Investigator (FI): Organizes and conducts detailed examinations of information generated during complex financial criminal/civil investigations and information available through alternative sources for the purpose of conducting financial analyses of personal/business assets of targeted organizations/individuals. Utilizes information obtained as a result of the financial analysis and prepares documentation for use by law enforcement personnel pursuing civil and criminal forfeiture matters. For the SFI, a minimum of ten years (five years for the FI) of law enforcement experience planning, conducting, and participating in complex financial investigations with a minimum of five years in a specialized area of expertise such as Forfeiture, Organized Crime, White Collar Crime, Fraud, Drug, Money Laundering, or similar area of criminal activity is required. An undergraduate degree is required. The SFI and FI must possess working knowledge of current financial investigative techniques, including the use of commercial databases and other sources of information, and a valid driver's license. Foreign language skills are preferred. Forfeiture Support Services (a) Develop the forfeiture processes and procedures associated with an on-going financial investigation. This support shall include the introduction of specific tools and techniques to analyze financial information. The contractor will provide advice and guidance to fully develop the forfeiture aspects of an ongoing investigation. Advice and guidance include, but is not limited to, education of the investigating agencies' agents on specific tools and techniques utilized to analyze financial information. Tasks performed to meet this requirement would include informal and formal training sessions based on the contractor's content or design and distribution of reference guides. (b) Analyze financial records obtained by the Investigating Agencies through internal and external data bases and submit reports documenting the results, when requested. Specifically, the contractor will review bank statements; deposits; and debit transactions, including checks, letters of credit, Currency Transaction Reports (CTR), loan applications, and related records that are obtained pursuant to Federal and State subpoenas and search warrants executed by the Government. The contractor will review the documents to determine hidden assets and false statements that are used to hide illicit assets from investigators and to make the assets appear to be legitimate. (c) Review, process, and analyze information sufficient to 1) assist in determining the amount to seek for forfeiture; 2) identify and trace assets during the course of investigations; and 3) assist the Government in perfecting its interest in the property. (d) Assist in the location and repatriation of assets that are subject to forfeiture. (e) Identify the individuals and entities making deposits and all related bank accounts, properties, investments, and any other assets that may be identified from the documentation. (f) Maintain detailed case documentation and database files of financial investigative research to trace proceeds of criminal activities and investigative interests in targeted property. (g) Research and analyze information derived from various investigative and business-related automated systems including, but not limited to, Choice Point, Autotrack, TECS, FINCEN, CLEAR, THREADS, Accurint, ISYS, Lexis-Nexis, PACER, CourtLink, West Law, NADA, Used Price.com, and other Internet capabilities (e.g., law enforcement databases to provide forfeiture specific case support to the Government in civil and criminal forfeiture matters). Examples of research and analysis activities include: analyzing and documenting the ownership interests of targeted properties; analyzing financial records to trace the proceeds of criminal violations to their current form; creating a data base from financial records to document the source of targeted property; preparing seizure warrants, civil complaints, and forfeiture counts; preparing exhibits on the source and ownership of targeted property; documenting and cataloguing evidence on the source and ownership of targeted property; and identifying, analyzing, and documenting potential substitute assets. (h) Research and identify assets utilizing various Social Media and Cyber research tools. (i) Provide additional services, including the parsing of dialed number strings, to identify amounts and property that may be subject to forfeiture in a particular investigation and to perfect the Government's interest in forfeitable property. (j) Organize and conduct detailed examinations of information generated during complex criminal/civil investigations as well as alternative sources for the purpose of conducting financial analyses of personal/business assets of targeted organizations/individuals. (k) Assist with the development of sufficient probable cause to enable the Government to pursue seizure warrants, temporary restraining orders, civil complaints, and forfeiture counts against targeted property and parties. (l) Provide investigative support to the Government with coordinated planning to mitigate excessive risks in seizing targeted property. This includes assessing impacts on the local community. An example would be the seizure of an occupied apartment complex. (m) Prepare documents and catalog case exhibits on the source and ownership of targeted properties. (n) Perform analytical research to identify and record potential substitute assets. (o) Identify witnesses and subjects and assist the case agent/attorney during -conducted interviews and courtroom proceedings regarding the ownership and source of targeted property of ongoing case investigations. (p) Provide courtroom testimony and depositions regarding their investigative analysis and identification of assets derived from specific unlawful activities. (q) Conduct detailed link analyses, specific to Forfeiture, utilizing the results of financial analysis and other investigative techniques, such as Title III's surveillance to determine relationships between the subjects of the investigation and the events that lead to the alleged forfeitability of property and proceeds. (r) Research and identify assets utilizing data amplification programs/systems and through various forms of cryptocurrencies (e.g., Bitcoin).

DEA AFISS 2 JOB DESCRIPTION Senior Financial Investigator (SFI) and Financial Investigator (FI): Organizes and conducts detailed examinations of information generated during complex financial criminal/civil investigations and information available through alternative sources for the purpose of conducting financial analyses of personal/business assets of targeted organizations/individuals. Utilizes information obtained as a result of the financial analysis and prepares documentation for use by law enforcement personnel pursuing civil and criminal forfeiture matters. For the SFI, a minimum of ten years (five years for the FI) of law enforcement experience planning, conducting, and participating in complex financial investigations with a minimum of five years in a specialized area of expertise such as Forfeiture, Organized Crime, White Collar Crime, Fraud, Drug, Money Laundering, or similar area of criminal activity is required. An undergraduate degree is required. The SFI and FI must possess working knowledge of current financial investigative techniques, including the use of commercial databases and other sources of information, and a valid driver's license. Foreign language skills are preferred. Forfeiture Support Services (a) Develop the forfeiture processes and procedures associated with an on-going financial investigation. This support shall include the introduction of specific tools and techniques to analyze financial information. The contractor will provide advice and guidance to fully develop the forfeiture aspects of an ongoing investigation. Advice and guidance include, but is not limited to, education of the investigating agencies' agents on specific tools and techniques utilized to analyze financial information. Tasks performed to meet this requirement would include informal and formal training sessions based on the contractor's content or design and distribution of reference guides. (b) Analyze financial records obtained by the Investigating Agencies through internal and external data bases and submit reports documenting the results, when requested. Specifically, the contractor will review bank statements; deposits; and debit transactions, including checks, letters of credit, Currency Transaction Reports (CTR), loan applications, and related records that are obtained pursuant to Federal and State subpoenas and search warrants executed by the Government. The contractor will review the documents to determine hidden assets and false statements that are used to hide illicit assets from investigators and to make the assets appear to be legitimate. (c) Review, process, and analyze information sufficient to 1) assist in determining the amount to seek for forfeiture; 2) identify and trace assets during the course of investigations; and 3) assist the Government in perfecting its interest in the property. (d) Assist in the location and repatriation of assets that are subject to forfeiture. (e) Identify the individuals and entities making deposits and all related bank accounts, properties, investments, and any other assets that may be identified from the documentation. (f) Maintain detailed case documentation and database files of financial investigative research to trace proceeds of criminal activities and investigative interests in targeted property. (g) Research and analyze information derived from various investigative and business-related automated systems including, but not limited to, Choice Point, Autotrack, TECS, FINCEN, CLEAR, THREADS, Accurint, ISYS, Lexis-Nexis, PACER, CourtLink, West Law, NADA, Used Price.com, and other Internet capabilities (e.g., law enforcement databases to provide forfeiture specific case support to the Government in civil and criminal forfeiture matters). Examples of research and analysis activities include: analyzing and documenting the ownership interests of targeted properties; analyzing financial records to trace the proceeds of criminal violations to their current form; creating a data base from financial records to document the source of targeted property; preparing seizure warrants, civil complaints, and forfeiture counts; preparing exhibits on the source and ownership of targeted property; documenting and cataloguing evidence on the source and ownership of targeted property; and identifying, analyzing, and documenting potential substitute assets. (h) Research and identify assets utilizing various Social Media and Cyber research tools. (i) Provide additional services, including the parsing of dialed number strings, to identify amounts and property that may be subject to forfeiture in a particular investigation and to perfect the Government's interest in forfeitable property. (j) Organize and conduct detailed examinations of information generated during complex criminal/civil investigations as well as alternative sources for the purpose of conducting financial analyses of personal/business assets of targeted organizations/individuals. (k) Assist with the development of sufficient probable cause to enable the Government to pursue seizure warrants, temporary restraining orders, civil complaints, and forfeiture counts against targeted property and parties. (l) Provide investigative support to the Government with coordinated planning to mitigate excessive risks in seizing targeted property. This includes assessing impacts on the local community. An example would be the seizure of an occupied apartment complex. (m) Prepare documents and catalog case exhibits on the source and ownership of targeted properties. (n) Perform analytical research to identify and record potential substitute assets. (o) Identify witnesses and subjects and assist the case agent/attorney during -conducted interviews and courtroom proceedings regarding the ownership and source of targeted property of ongoing case investigations. (p) Provide courtroom testimony and depositions regarding their investigative analysis and identification of assets derived from specific unlawful activities. (q) Conduct detailed link analyses, specific to Forfeiture, utilizing the results of financial analysis and other investigative techniques, such as Title III's surveillance to determine relationships between the subjects of the investigation and the events that lead to the alleged forfeitability of property and proceeds. (r) Research and identify assets utilizing data amplification programs/systems and through various forms of cryptocurrencies (e.g., Bitcoin).

We offer a merit-based work-from-home program based on job responsibilities. After initial training in-person, you could have the flexibility of work-from-home time as defined by the leadership team. Auto-Owners Insurance, a top-rated insurance carrier, is seeking an experienced and motivated Claims Investigator professional to join our Special Investigation unit. The position requires the following, but is not limited to: * Become familiar with the specialized investigation of claims * Meet with people involved with claims. This may be outside our office environment. * Increased role as a trainer/resource for branch associates in the Claims Department. * Develop and present educational materials to claim associates that focus on fraud awareness/investigation. Desired Skills & Experience * Bachelor's degree or equivalent experience. * Ability to handle conflict comfortably. * Field Claim Rep with Auto and Field experience preferred. * Ability to read, interpret and react to documents such as insurance policies, procedures manuals, and legal documents. * Able to assemble information, develop opinions and clearly express decisions using sound reasoning and judgment. * Ability to write reports and compose correspondence. * Ability to communicate, both verbally and in writing, and possess good problem resolution skills and good interpersonal skills. * Able to accurately deal with mathematics and financial areas and develop an understanding of personal and business finance documents. * Can tactfully and effectively deal with all types of people. * Able to drive an automobile, possess a valid driver license, and maintain a driving record consistent with the Company's underwriting guidelines for coverage. * Ability to organize assigned work. * Ability to maintain a professional image. Benefits Auto-Owners offers a wide range of career opportunities, and we are seeking talent that will help us continue our long tradition of success. We offer a friendly work environment, structured training program, employee mentoring and an excellent compensation/benefits package. Along with a competitive base salary, matched 401(k), fully-funded pension plan (once vested), and bonus programs, Auto-Owners also provides generous paid time off including holidays, vacation days, personal time, and sick leave. If you're looking to do rewarding work alongside great people, Auto-Owners is the place for you! Equal Employment Opportunity Auto-Owners Insurance is an equal opportunity employer. The Company hires, transfers, and promotes on the basis of ability, without consideration of disability, age, sex, race, color, religion, height, weight, marital status, sexual orientation, gender identity or national origin, or any factor contrary to federal, state or local law. * Please note that the ability to work in the U.S. without current or future sponsorship is a requirement. #LI-AT1 #LI-Hybrid

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start **Caring. Connecting. Growing together.** Work at home! The Medical Director for UnitedHealthcare's Investigations Unit (UHC IU) is a valuable national leader for UnitedHealthcare. The Medical Director oversees a coding team, ensuring accurate and efficient healthcare payments, accurate appeal outcomes, and collaborates with clinical and coding teams across UnitedHealthcare and Optum, as well as UHG business leaders and stakeholders, to drive informed decision-making and optimize outcomes. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week. **Primary Responsibilities:** + Oversee and perform medical record reviews of retrospective medical claims relative to fraud, waste and abuse to include all levels of complexity + Have the ability to review/code a variety of medical records using CPT, HCPCS and ICD-10 codes for office, outpatient, inpatient, surgical, hospital ancillary, nursing facility, urgent care, ambulatory surgery center and other charges for physicians and other providers of professional billing + Provide clinical oversight and guidance to UHC IU medical record review team and UHC IU investigative staff + Serve as a resource and Subject Matter Expert for team members in the UHC IU + Document medical review findings on a claim level and draft reports of findings, actions and outcomes to be relied on in investigations of fraud, waste, and abuse cases in accordance with policies, and regulatory and accreditation requirements + Ensure compliance with the UnitedHealthcare (UHC) Fraud, Waste and Abuse policies and other federal/state regulations or contractual obligations + Communicate with UnitedHealthcare investigative staff regarding coding/clinical rationales + Supply all criteria that was relied on, supporting all recommendations for denial or modification of claim payment errors + Serve as a clinical resource for team members in the UHC IU + Support the UHC IU in their interactions with providers to explain review/ medical record review findings and the application of coding/clinical criteria + Engage with requesting providers as needed in peer-to-peer discussions + Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results + Provide clinical and strategic input when participating in organizational committees, projects, and task forces + Develop quality audit practices to ensure UHC SIU's Medical Record Review Team is adhering to proper coding/clinical guidelines and ensuring clinical justification meets expected standards You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + MD or DO with an active, unrestricted license + Board certification approved by the American Board of Medical Specialties (ABMS/AOBMS) + 5+ years of clinical practice experience + Familiarity with current medical issues and practices + Proficiency in performing medical record case reviews in accordance with established reimbursement and medical policies + Intermediate or higher level of proficiency with managed care + Proven excellent telephonic communication skills; excellent interpersonal communication skills + Proven solid critical thinking and analytic skills + Proven ability to manage multiple competing priorities + Demonstrated ability to communicate effectively, to include written and verbal forms of communication + Proven data analysis and interpretation skills + Proven excellent presentation skills for both clinical and non-clinical audiences + Proven creative problem-solving skills + Proven excellent computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet research skills + Proven solid team player and team building skills **Preferred Qualifications:** + Coding certification (CPC, CCS, etc.) + Knowledge and experience in health care fraud, waste, and abuse (FWA) investigations + Broad knowledge and experience in state and federal regulatory FWA requirements *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes base pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._