You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Pharmacy FWA Investigator - Fraud, Waste and Abuse

Position Purpose: Investigates allegations pertaining to Pharmacy Fraud, Waste and Abuse and develops strategies to effectively research specific FWA schemes. Recommends effective remedial actions of a pharmacy (e.g., pharmacy network termination; corrective action plans) when a credible allegation of fraud exists. Proactively analyzes pharmacy claims and other available data sources to identify FWA schemes.

Investigates allegations pertaining to Pharmacy Fraud, Waste and Abuse and develops strategies to effectively research specific FWA schemes.

Prepares and submits evidentiary documents and prepares cases for presentation to the Pharmacy Network Review Committee (PNRC).

Accurately documents investigations and aggregates data for internal reporting of outcomes and recoveries.

Prepares cases for referral to appropriate parties as determined by the evidence and regulatory requirements.

Proactively analyzes pharmacy claims and other available sources of data to identify FWA schemes and aberrant activity to generate pharmacy leads.

Recommends effective remedial actions of a pharmacy (e.g., pharmacy network termination; corrective action plans) when a credible allegation of fraud exists.

Education/Experience: Associate’s degree in a related field or equivalent combination of experience. Pharmacy Technician or Pharmacy Coordinator (i.e. hospital and/or retail environments or related experience with a Health Plan or Pharmacy Benefit Manager).

Preferred - 2+ years of experience in claims auditing and/or pharmacy investigations

Preferred -- Previous experience with government programs such as Medicare and Medicaid

License/Certification:

Preferred - Certified Pharmacy Technician (CPhT)

Preferred - Accredited Health Care Fraud Investigator (AHFI)

Additional job specific details and skills:

Proficiency with Excel and databases

Analytical skills - Data analysis, claims analysis and reports with large volumes of claims

Thrives on data analysis and frequent change in direction

Experience utilizing strategies to improve processes

Exceptional critical thinking skills

Strong decision making and problem-solving skills

Good organization and time-management skills

FWA or audit experience, highly preferred

Working shift: 8am - 5pm or 8:30am - 5pm Monday - Friday (Eastern / EST)

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.  Total compensation may also include additional forms of incentives.

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