Fraud Analyst - Pharmacy

Job ID: J130197
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Sep 6, 2018

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Description

JOB SUMMARY

This job maintains the Designated Pharmacy Program (DPP) which includes reviewing medical and prescription drug claims to identify members who exhibit unsafe prescription drug behavior and help members obtain care alignment and/or addiction treatment.  The incumbent reviews high prescriber investigations, works with MD's to assess medical necessity of medications and identify potential red flags of fraud across provider prescribing patterns, etc.

ESSENTIAL RESPONSIBILITIES

  • Maintain the Designated Pharmacy Program (DPP) which includes reviewing medical and prescription drug claims to identify members who exhibit unsafe prescription drug behavior and help members obtain care alignment and/or addiction treatment. 
  • Conduct review of areas or programs as requested both internally and externally using department case protocol: (a) Identify high prescribers by reviewing inquiries/complaints, data mining reports, etc., (b) Interview providers, members or any other individual(s) necessary to complete a case review or special project, (c)  Determine the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctor’s agreements, contract, etc., (d)  Coordinate data extracts by assessing multiple databases both internally and externally, and (e) Take action to prevent further improper payments.
  • Review and analyze claims data, applying knowledge of pharmacy policy/practice and data mining techniques to determine details of over-payment billing activity while assisting with oversight of program.
  • Monitor and report accordingly any compliance issues with regulatory requirements.
  • Identify and document fraudulent or erroneous activities.
  • Participate in Pharmacy related Fraud, Waste and Abuse measurement projects, helping to develop enhanced data analysis systems and serving as a resource for developing Fraud, Waste and Abuse investigative results and solutions.  
  • Handle allegations of potential pharmacy fraud.
  • Review and analyze claims data, applying knowledge of pharmacy policy/practice and data mining techniques to determine details of overpayment billing activity while assisting with oversight of contracted program.
  • Other duties as assigned or requested.

EDUCATION

Required

  • High School/GED

Substitutions

  • None

Preferred

  • Pharmacy Technician

EXPERIENCE

Required

  • 3 years Pharmacy Technician or Pharmacy Audit

Preferred

  • None

LICENSES or CERTIFICATIONS

Required

  • None

Preferred

  • Pharmacy Technician

SKILLS

  • Oral and Written Communication Skills
  • General Computer Skills
  • Problem Solving and Decision Making
  • Compliance
  • Prioritization

Language

None

Travel Requirements

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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