Senior Pharmacy Fraud Investigator

Job Summary

Independently leading complex fraud, waste, and abuse investigations, the full-time Senior Pharmacy Fraud Investigator will utilize advanced investigative techniques and data analysis to identify misconduct and support corrective actions while working remotely.

Key responsibilities

• Conducts investigations involving providers, members, pharmacies, and vendors using various investigative resources
• Analyzes claims, billing patterns, and medical records to identify potential fraud and compliance concerns
• Prepares comprehensive reports and collaborates with stakeholders to support investigative activities and case resolutions

Required qualifications

• Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; Master's Degree preferred
• 4+ years of experience in fraud investigations, healthcare compliance, or related investigative work
• Experience leading complex investigations and preparing reports for regulatory agencies and law enforcement
• Knowledge of federal and state healthcare regulations, including Medicaid and Medicare
• Preferred certifications include Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)