Prime Therapeutics · 14 hours ago
SIU Specialist/Pharmacy Tech - Remote in the California market
United States
Full-time
Remote
New Grad, Entry Level
$21.15/hr - $31.73/hr
0+ years expPrime Therapeutics is a unique pharmacy benefit manager focused on connecting care for those they serve. The Associate SIU Specialist is responsible for handling allegations of fraud, waste, or abuse, conducting preliminary investigations, and maintaining compliance with relevant regulations.
Health CarePharmaceutical
No H1B
Responsibilities
Intake and maintain caseload of FWA incidents/allegations; prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements
Analyze and identify suspicious FWA activity leveraging knowledge of health care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant policies along with state and federal regulations; follow protocols to identify instances of potential FWA through data analysis using a variety of analytics, systems, tools, and industry resources
Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation; collaborate and refer non-SIU related issues and activities to external departments (Appeals & Grievances, Networks, Clinical) for handling
Organize data, document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations
Other duties as assigned
Qualification
Required
Bachelor's degree in Business, Criminal Justice, Healthcare or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required
Must be eligible to work in the United States without the need for work visa or residency sponsorship
Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision
Ability to review and evaluate data and information to identify suspicious patterns
Strong verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers
Ability to work cooperatively with others to foster trust and collaboration across the enterprise
Ability to think critically and solve problems
Demonstrates an understanding of health care coding conventions, fraud schemes, reimbursement methodologies, policy interpretation, and state and federal regulations
Basic understanding of Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications
Preferred
PBM/health care experience
Certified Fraud Examiner (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification
Certified Pharmacy Technician (CPhT)
Company
Prime Therapeutics
Prime Therapeutics is a trusted pharmacy solutions partner delivering savings, simplicity & support to our customers and members
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Mostafa Kamal
President & Chief Executive Officer
Kenneth Bodmer
Chief Financial Officer
Recent News
2025-10-31
Company data provided by crunchbase