SIU Clinical Consultant

Our work matters. We help people get the medicine they need to feel better and live well.  We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Job Description

Responsibilities

• Leverage clinical judgement to evaluate members for potential prescriber, pharmacy and drug restrictions (i.e. FWA lock ins) based on substantiated SIU investigations; recommend FWA lock ins and proactively lead internal and external discussions to implement appropriate restriction; identify and secure prescriber engagement to manage member restrictions; effectively communicate outcomes to department leadership and other internal or external stakeholders; act as primary point of contact for member and prescriber outreach and inquiries regarding the FWA lock in
• Act in advisory capacity by providing clinical input to investigators during their cases; evaluating risk to determine how best to proceed with investigations based on the allegations; manage and evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; ensure adherence across the SIU regarding evidentiary requirements, quality metrics, and other performance indicators required per SIU procedures
• Proactively contribute clinical expertise to department and client initiatives; engage in cross functional analysis of medical and pharmacy claims; lead FWA investigations for federal employee program
• Stay current on industry trend and best practices to understand potential clinical fraud indicators and risk mitigation; contribute clinical expertise to department projects and initiatives by making recommendations to audit operations, SIU and FWA analytics regarding enhancements or required changes to process; and drive the implementation and subsequent training efforts to support new and changing processes
• Other duties as assigned

Education & Experience

• Bachelor's degree in Nursing or related area of study, or equivalent combination of education and/or relevant work experience

• 5 years of work experience in case management or professional practice
• Current Registered Nurse (RN) license in good standing with the Board of Nursing as required by the state of employment operation
• Must be eligible to work in the United States without need for work visa or residency sponsorship

Must be eligible to work in the United States without the need for work visa or residency sponsorship.

Additional Qualifications

• Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need while working with a high degree of autonomy
• Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions
• Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders
• Ability to distill complex concepts or situations into concise and compelling communications
• Ability to interact positively and professionally during all member, prescriber and pharmacy interactions and effectively de-escalate potentially confrontational situations
• Knowledge and understanding of pharmacy or medical claims processing environment

Preferred Qualifications

• Certified Fraud Examiner or Accredited Health Care Fraud Investigator
• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
• Prior experience in a special investigation's unit

Physical Demands

• Constantly required to sit, use hands to handle or feel, talk and hear
• Frequently required to reach with hands and arms
• Occasionally required to stand, walk and stoop, kneel, and crouch
• Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.