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ROLE OVERVIEW

Under direct supervision of the Director, SIU the Pharmacy Manager in the Special Investigations Unit (SIU) will lead efforts to detect, investigate and prevent healthcare fraud within the pharmacy operations. ; This role combines subject matter expertise in pharmacy practices with advance fraud detection and compliance strategies. ;The ideal candidate will play a pivotal role in safeguarding the integrity of pharmacy services and ensuring adherence to legal standards while minimizing risks to the organization. ;

The manager must have the ability to determine correct coding, review claims, medical records and billing data from all types of healthcare providers for aberrant billing patterns. ;Duties include managing case assignments, case development, case review, overpayment recoveries, state agency and / or law enforcement referrals, training of staff, and coordination with other departments to mitigate and remedy fraud, waste and abuse. ;Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends and schemes.;

WORK ARRANGEMENT

This position is a remote eligible position working East Coast hours. ;Quarterly travel required to corporate office.;

RESPONSIBILITIES

+ Accountable for the performance of assigned SIU investigative analysts/investigators/ team leads.;

+ Manages day-to-day activities of assigned SIU investigative analysts/investigators by assigning cases to staff based on skills and resources to ensure appropriate prioritization of cases; fostering a collegial and positive work environment; managing, mentoring, and directing individual and team performance; monitoring progress with individual and team performance goals.

+ Proactively identify and analyze patters or anomalies in pharmacy claims and operations indicative of fraud, waste and abuse.;

+ Lead and manage investigations into suspected fraudulent activities within pharmacy operations.

+ Gather and evaluate evidence documenting findings in a clear and professional manner for use in potential legal or regulatory proceedings.

+ Performing sampling methodologies for medical record requests/reviews (e.g., OIG SVRS tool, Probe or random sampling).

+ Develops and implements plan for prospective and retrospective FWA avoidance, detection, investigation, and recovery.;

+ Prepare comprehensive investigation reports and communicate recommendations to leadership and relevant regulatory bodies. ;

+ Monitors compliance with company policies and procedures and compliance with pertinent FWA provisions of state contracts.;

+ Coordinates SIU pharmacy activities with other departments, providers, members, vendors, regulatory and law enforcement agencies.;

+ Develop and apply data driven methodologies to monitor pharmacy claims and transactions for irregularities, leveraging industry-specific tools and technologies.;

+ Coordinates litigation support for SIU matters referred to Legal Affairs.;

Education/Experience: ;

+ Bachelor’s Degree or equivalent work experience.;

+ Healthcare experience required.;

+ Maintain current knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.

+ Credentials such as Certified Fraud Examiner, Accredited Healthcare Fraud Investigator, Certified Insurance Fraud Investigator, Certified Internal Auditor, or other similar licensure/certification is required.

+ Excellent leadership, team building and strategic thinking skills.

+ Excellent verbal and written communication skills.

+ Minimum of 5 years of experience in pharmacy operations with a focus on compliance audit or fraud prevention. ;

+ Proficiency in MS-Office applications (MS-Word, MS-Excel, MS-Access, MS-PowerPoint, and MS-Outlook) required.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com .

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.