Manager Pharmaceutical Financial Investigations and Provider Review
Core
Leading a team of investigators to detect and resolve fraud, waste, and abuse (FWA) in pharmaceutical cases, focusing on drug diversion, designated pharmacy programs, and Medicare compliance.
Role type
Manager, Pharmaceutical Financial Investigations and Provider Review
Builds
Recovery of overpayments and resolution of FWA cases within the pharmaceutical and drug benefit domain
Domain
Healthcare / Pharmaceutical Financial Investigations
Deliverable
client delivery
Required skills
Team leadership, case investigation strategy, regulatory compliance knowledge, financial data analysis, audit management, legal procedure knowledge, stakeholder communication
Preferred skills
Managed care pharmacy experience, Pharmacy Benefit Management (PBM) operations, clinician supervision
Technologies
Pharmacy benefit management systems, audit tools, regulatory databases
Responsibilities
Manage hiring, termination, coaching, and performance of the investigation team; Develop detailed strategies for FWA cases; Collaborate with law enforcement and external legal counsel; Present provider appeal cases to the Medical Review Committee; Lead process improvements and workflow efficiency initiatives
Seniority
Manager, team leadership