Reports to: Sr. Manager Pharmacy FWA
Location: 4110 George Road, Tampa FL 33634
Reviews pharmacy claim reports to detect potential errors, abnormalities, and outlier patterns. Investigates allegations and issues pertaining to pharmacy Fraud, Waste and Abuse including research of federal and state statutory, regulatory and contractual requirements as required. Works with internal and external partners to resolve inappropriately processed claims and triage credible allegations of fraud or abuse.
Additional Responsibilities:Candidate Education:
- As part of the pharmacy department, reviews pharmacy claims data, including outlier and trending reports, in order to detect inappropriate billing and/or potential fraud, waste or abuse.
- Using a systematic approach, conducts effective preliminary investigations of pharmacy FWA referrals. Gathers sufficient evidence and generates reports required to effectively evaluate an allegation of pharmacy FWA.
- Reviews and analyzes reports and evidence gathered from preliminary investigations of pharmacy FWA referrals to draw accurate conclusions as to the presence or absence of a credible allegation of fraud.
- Documents investigations, including preliminary and final case reports, for both internal tracking and regulatory reporting purposes.
- Maintains case files of all evidence and relevant information and uses a business management application to clearly and concisely document allegations, internal and external communications, key findings, resolutions, outcomes, recoupments and other pertinent case information.
- Works with internal (e.g., SIU) and external (e.g., Pharmacy Benefit Manager) partners to resolve inappropriately processed claims and triage credible allegations of fraud or abuse.
- Prepares cases for referral to the Special Investigations Unit and/or the Pharmacy Benefit Manager when a preliminary investigation warrants an onsite or investigative audit due to potential fraud or abuse.
- Applies federal and state regulatory and contractual requirements as well as plan benefit information to pharmacy FWA claim reviews and investigations.
- Conducts ad-hoc projects and claim reviews to determine compliance with specific CMS regulations and completes other duties as assigned.
- Monitors and reports to management on the status of assigned projects, anticipating and identifying issues that could inhibit achieving the project goals and objectives, and implementing corrective actions and mitigation strategies.
- Consolidates data for reporting of recoupments, savings and avoidance as assigned.
- Maintains confidentiality of all sensitive information.
- Additional projects as assigned.
- Required An Associate's Degree in a related field or equivalent combination of experience
- Required 2 years of experience in Pharmacy Technician Work (i.e. Hospital and/or retail environments or related experience with a Health Plan or Pharmacy Benefit Manager)
- Preferred 2 years of experience in Pharmacy PBM and/or claims monitoring review
- Preferred Other Previous experience with government programs such as Medicare and Medicaid
Licenses and Certifications:
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Other Ability to understand and follow statutory, regulatory and contractual requirements, verbal instructions, and written polices and procedures
- Intermediate Ability to drive multiple projects
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Demonstrated ability to deal with confidential information
A license in one of the following is required:
- Preferred Certified Pharmacy Technician (CPhT)
- Required Intermediate Windows Operating System
- Required Intermediate Microsoft Outlook
- Preferred Intermediate Microsoft Word
- Preferred Intermediate Microsoft Excel
- Preferred Intermediate Microsoft Access
- Preferred Intermediate Microsoft PowerPoint