Prime Therapeutics Associate Pharmacy Claims FWA Analyst - Remote in Boston, Massachusetts
Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.
Job Posting Title
Associate Pharmacy Claims FWA Analyst - Remote
The Associate Fraud, Waste and Abuse (FWA) Analyst will support the assigned business area in triaging potential cases to Prime’s Pharmacy Audit and Special Investigation Unit (SIU) operations team. During the process this role is expected to research, analyze, and compile supporting information. This role will also support FWA projects and practices in identifying FWA trends and schemes.
Research and collect information to aid in the identification of FWA trends
Support triage of suspected FWA leads to appropriate business area along with compiled research and data meeting established triage efficacy rate while tracking all activity and data quality to support operational and performance reporting
Adhere to business processes of assigned business area and share enhancement or improvement recommendations that impact fraud case selection in collaboration with other team members to assist in the development and implementation of new or enhanced practices
Follow protocols to identify instances of potential FWA through data analysis using a variety of analytics, systems tools, and industry resources
Leverage knowledge of heath care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant policies along with state and federal regulations to identify suspicious FWA activity
Support Prime’s Fraud Tip Hotline by regularly logging hotline reports, triaging to the appropriate business area, and escalating to senior team members when appropriate while ensuring hotline reports are triaged within the pre-defined timeline
Other duties as assigned
Associate’s degree in Business, Criminal Justice, Health Information Management or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
1 year of work experience in fraud investigation, analytics audit, or pharmacy/medical billing
Must be eligible to work in the United States without need for work visa or residency sponsorship
Ability to communicate and present data effectively
Demonstrates an ability to work cooperatively with others; fosters trust and collaboration across the enterprise
Ability to think critically and problem solve
Intermediate proficiency with MS Office suites such as Access, Excel, PowerPoint, and Word
Demonstrates an understanding of health care coding conventions, fraud schemes, reimbursement methodologies and state and federal regulations
PBM/health care experience
Experience with SAS or SQL
Certified Fraud Examiners (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification
Minimum Physical Job Requirements
Constantly required to sit, use hands to handle or feel, talk and hear
Frequently required to reach with hands and arms
Occasionally required to stand, walk and stoop, kneel, and crouch
Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus
- Reports to Manager in the Pharmacy Audit and FWA department
Potential pay for this position ranges from $22.45 - $31.78 based on experience and skills. Pay range may vary by 8% depending on applicant location.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (https://www.primetherapeutics.com/careers/benefits/) and click on the "Benefits at a glance" button for more detail.
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, genetic information, marital status, family status, national origin, age, disability, veteran status, or any other legally protected class under federal, state, or local law.
Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.
If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at 1.866.469.1257 or email Careers@primetherapeutics.com.
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