Audit Claims Investigator

• Analyze and evaluate potential fraud and abuse situations using corroboratory information obtained through correspondence with members, physicians, and pharmacies
• Identify and investigate cases of suspected fraud and high 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 and clients, expressing the findings of completed investigations
• Prepare for and take a 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
• Manage fraud tips (through emails, fraud tip line, client referrals, etc.). Track and monitor the status of each investigation
• Conduct desk and physical on-site inspections
• Attend industry‑related anti‑fraud meetings or conferences as required
• Work with the Data Analytics team to enhance profiling and fraud reporting requirements based on emerging risks
• Support internal initiatives and projects as assigned

• Bachelor’s degree or equivalent work experience
• 2–5 years of relevant experience as a pharmacy technician, health care professional, or data analyst
• 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 the ability to present to clients and internal stakeholders
• Ability to travel nationwide as needed for physical on-site inspections
• Ability to work well with senior management and high‑level external contacts, handle sensitive or confidential information which is critical, and work with minimum management oversight on multiple projects with competing priorities
• Ability to work a flexible schedule to accommodate project deadlines

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

• Competitive compensation, benefits and pension plan
• Career development and advancement opportunities
• A culture that celebrates innovation and collaboration
• Flexible work options and wellness programs