Manager Pharmaceutical Financial Investigations and Provider Review

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job is responsible for the daily activities of the Financial Investigations & Provider Review (FIPR) department with emphasis on pharmaceutical cases and initiatives. FIPR focuses on the detection and investigation of fraud, waste and abuse (FWA) and the recoupment of related overpayments related to the company’s provider spending. The incumbent will function as a key leader guiding all of the daily activities for a strategic unit within the department: The Pharmaceutical FWA unit. This job will be accountable for leading a team of investigators dedicated to cases and initiatives associated with pharmaceutical and drug related diversion, designated pharmacy programs, Medicare compliance mandates and other pharmaceutical related matters.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

• Delivers daily guidance to team leads and staff regarding case investigation activities including the development of detailed strategies for each case. Educates staff and management on regulatory and customer requirements regarding FIPR’s scope of activities and ensure adherence to these requirements.

• Provides direction to a team of investigators as members of a multi-stakeholder team responsible for monitoring drug utilization across the pharmacy and medical benefit with the goal of detecting and resolving instances of FWA.

• Develops action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by pharmacy/prescriber investigations and analysis activities.

• Actively communicates and collaborates with management from various departments regarding impact on provider relations and reimbursement. Serves as subject matter expert for staff on the fraud investigation, facility and vendor audit and opportunity teams.

• Provide suggestions on and/or participate in department projects, process improvements, efficiency initiatives, system enhancements and policy and procedures to improve workflows.

• Serves in a variety of capacities in representing the department, including but not limited to such activities as:

• Working with audit vendors to refine their approaches and generate consistent increase in their recoveries

• Testifying when required in legal proceedings

• Collaborating with law enforcement in the pursuit of cases referred for prosecution

• Presenting provider/network appeal cases to Medical Review Committee (MRC); and/or providing technical expertise in evaluating/resolving cases.

• Interacting with external legal counsel regarding case inquiries

• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor’s degree in Pharmacy or related field or related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• Master's Degree or above in Pharmacy or related field

EXPERIENCE

Required

• 5 years of auditing, leading provider / facility audits and/or provider reimbursements, or in the health care industry with exposure to billing, coding

To Include:

• 3 years of clinical pharmacy management experience including drug use review activities, operational oversight and/or member engagement – knowledge of pharmacy/drug related FWA and experience working with law enforcement agencies (e.g. DEA)

• 1 year working with regulatory entities such as CMS, NCQA, HEDIS, and DOH etc.

Preferred

• 3 years in a managed care pharmacy and/or pharmacy benefit management (PBM)

• 1 years in managing or supervising clinicians (such as pharmacists, nurses, or other clinicians) in a utilization management operations setting in a PBM or Health Plan.

LICENSES or CERTIFICATIONS

Required

• Pharmacist License

Preferred

• None

SKILLS

• Strong analytic skills with ability to interpret, evaluate and act on productivity, clinical and financial data

• Strong leadership skills with demonstrated success in building effective, collaborative teams

• Ability to work in a high performing team environment that requires flexibility

• Strong and effective verbal and written communication skills; Effectively presents complex topics in a concise manner to audiences at various levels and various sizes; Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach

• Knowledge of hospital reimbursement strategies; medical technologies, hospital and provider office protocols, documentation requirements, State and Federal criminal and civil law related to insurance fraud and advances in the post-payment utilization review process

• Self-confident with an ability to accept and respond to challenges in a positive manner

• Broad understanding of business issues, metrics, organizational linkages and customer value

• Comprehensive knowledge of legal and investigative procedures used in the detection and successful resolution of health care fraud/abuse cases

Language (Other than English):

None

Travel Requirement:

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

Never

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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

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 any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib\_458575\_QLVK9\_1769448333304228022\_1769448333396/1769448333396.pdf)

Req ID: J289819