Investigator Lead - Pharmacy
Core
Lead the Special Investigations Unit team in investigating, collecting, researching, and analyzing billing data to detect fraudulent, abusive, or wasteful activities within the healthcare industry.
Role type
Senior IC investigation lead (pharmacy focus)
Builds
Fraud detection cases, statistical/financial analyses, settlement offers, and policy recommendations
Domain
Healthcare insurance / Fraud investigation
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Healthcare insurance investigation, data analysis, statistical/financial reporting, case management, policy development, law enforcement liaison, court representation, team leadership
Preferred skills
PharmD, CPhT, pharmacy investigation experience, CFE, AHFI, CPC, Paralegal, RN, JD, benefit program negotiation
Technologies
System tools for data analysis
Responsibilities
Coordinate and conduct pharmacy case reviews for quality assurance and data management; prepare final reports and notification letters for providers and legal counsel; create and present settlement offers; communicate findings to internal and external stakeholders; assist in developing policies to prevent asset loss; represent the company in court proceedings; lead SIU projects or initiatives
Seniority
Senior, hands-on IC
