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Pharmacy FWA Investigator

Wellcare - Tampa, FL

Pharmacy FWA Investigator','1705727','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at or view our videos at All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.','!*!Department:  Pharmacy

Reports to:    Sr. Manager Pharmacy FWA

Location:      4110 George Road, Tampa FL 33634

 Reviews pharmacy claim reports to detect potential errors, abnormalities, and outlier patterns. Investigates allegations and issues pertaining to pharmacy Fraud, Waste and Abuse including research of federal and state statutory, regulatory and contractual requirements as required. Works with internal and external partners to resolve inappropriately processed claims and triage credible allegations of fraud or abuse. Essential Functions:

As part of the pharmacy department, reviews pharmacy claims data, including outlier and trending reports, in order to detect inappropriate billing and/or potential fraud, waste or abuse.

Using a systematic approach, conducts effective preliminary investigations of pharmacy FWA referrals. Gathers sufficient evidence and generates reports required to effectively evaluate an allegation of pharmacy FWA.

Reviews and analyzes reports and evidence gathered from preliminary investigations of pharmacy FWA referrals to draw accurate conclusions as to the presence or absence of a credible allegation of fraud.

Documents investigations, including preliminary and final case reports, for both internal tracking and regulatory reporting purposes.

Maintains case files of all evidence and relevant information and uses a business management application to clearly and concisely document allegations, internal and external communications, key findings, resolutions, outcomes, recoupments and other pertinent case information.

Works with internal (e.g., SIU) and external (e.g., Pharmacy Benefit Manager) partners to resolve inappropriately processed claims and triage credible allegations of fraud or abuse.

Prepares cases for referral to the Special Investigations Unit and/or the Pharmacy Benefit Manager when a preliminary investigation warrants an onsite or investigative audit due to potential fraud or abuse.

Applies federal and state regulatory and contractual requirements as well as plan benefit information to pharmacy FWA claim reviews and investigations.

Conducts ad-hoc projects and claim reviews to determine compliance with specific CMS regulations and completes other duties as assigned.

Monitors and reports to management on the status of assigned projects, anticipating and identifying issues that could inhibit achieving the project goals and objectives, and implementing corrective actions and mitigation strategies.

Consolidates data for reporting of recoupments, savings and avoidance as assigned.

Maintains confidentiality of all sensitive information.

Additional projects as assigned. Additional Responsibilities:

','!*!Candidate Education:

Required An Associate's Degree in a related field or equivalent combination of experience Candidate Experience:

Required 2 years of experience in Pharmacy Technician Work (i.e. Hospital and/or retail environments or related experience with a Health Plan or Pharmacy Benefit Manager)

Preferred 2 years of experience in Pharmacy PBM and/or claims monitoring review

Preferred Other Previous experience with government programs such as Medicare and Medicaid Candidate Skills:

Intermediate Demonstrated interpersonal/verbal communication skills

Intermediate Demonstrated written communication skills

Intermediate Other Ability to understand and follow statutory, regulatory and contractual requirements, verbal instructions, and written polices and procedures

Intermediate Ability to drive multiple projects

Intermediate Ability to effectively present information and respond to questions from peers and management

Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions

Intermediate Demonstrated ability to deal with confidential information Licenses and Certifications:A license in one of the following is required:

Preferred Certified Pharmacy Technician (CPhT) Technical Skills:

Required Intermediate Windows Operating System

Required Intermediate Microsoft Outlook

Preferred Intermediate Microsoft Word

Preferred Intermediate Microsoft Excel

Preferred Intermediate Microsoft Access

Preferred Intermediate Microsoft PowerPoint Languages:

','US-FL-Tampa','4110 George Road','','Tampa','33634','','','No','No','Pharmacy FWA Investigator'

7 days 15 hours ago



Pharmacy FWA Investigator Wellcare - Tampa, FL, United States


Location: Tampa, FL

Company Profile:
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.