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Staff Investigator Case Development at Express Scripts

Posted in Other 30+ days ago.

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Type: Full Time
Location: Bloomfield, Connecticut





Job Description:

POSITION SUMMARY

Identify member and prescriber fraud and abuse risks using critical thinking skills and fraud analytics software. Complete complex investigational audits in order to correct risks identified and protect client assets, and present findings both verbally and in writing to key internal and external stakeholders. Identify and recommend policy and procedures and systems changes to enhance case development efficiency and quality of cases. Coordinate investigations with client s SIUs and MEDICs as necessary. Assist in mentoring and developing Program Integrity team members.

ESSENTIAL FUNCTIONS

* Analyze and evaluate potential fraud and abuse situations using corroboratory information obtained by correspondence with members, physicians, and pharmacies.

* Identify and investigate cases of suspected fraud and abuse for assigned clients.

* Develop these cases in compliance with any applicable policies, procedures, or regulatory requirements.

* Prepare formal and thorough written reports to upper management, clients, and the Medicare Drug Integrity Contractors (MEDIC) expressing the findings of completed investigations.

* Prepare for and take lead role in client communications, including conference calls and on-site meetings, to present status updates of ongoing issues, results of completed investigations, etc., for assigned clients.

* Identify and perform special projects.

* Mentor and develop Program Integrity team members.

QUALIFICATIONS

* Bachelor s degree in related field or 8 to 11 years of experience.

* 2-5 years relevant experience with Bachelor s Degree or Master s degree and 0-3 years of relevant experience

* 2-5 years of relevant experience as a pharmacy technician, health care professional, or data analyst.

* Certified Pharmacy Technician, Certified Fraud Examiner, or similar certification strongly desired.

* Highly proficient in Microsoft Access & Excel, and data warehousing applications.

* Excellent organizational and interpersonal skills, critical thinking and planning skills, verbal and written communication skills, including ability to present to clients and internal stakeholders.

* Ability to work well with senior management and high level external contacts, handle sensitive or confidential information is critical, work with minimum management oversight on multiple projects with competing priorities.

* Ability to work a flexible schedule to accommodate project deadlines.

*LI-SO1

ABOUT THE DEPARTMENT

If your niche is in financial reporting and analysis, underwriting, cash management, audit or investor relations, our Finance department may be a perfect fit for you. Our teams within Finance work together to ensure that spending stays on track and that we remain a profitable industry leader. We re always on the lookout for innovative people who will bring outside-the-box thinking to our team.

ABOUT EXPRESS SCRIPTS

At Express Scripts, we dare to imagine a better health care system, and we re driven to make it happen. Where some see obstacles, we see possibilities. We re challengers, difference-makers and opportunity-seekers, united with our partners in pursuit of a simpler, more sustainable system and better health for all.

We have always acted first to take on the toughest challenges. We uniquely partner across the health care ecosystem to uncover opportunities, take action, advance health care and deliver better outcomes like no one else can. We believe health care can do more. We are Champions For BetterSM.

Express Scripts, part of Cigna Corporation, unlocks new value in pharmacy, medical and beyond to further total health for all..

Express Scripts is an equal opportunity employer/disability/veteran