Job Overview
Location
Home
Job Type
Full-time
Category
HR & Recruiting
Date Posted
March 22, 2026
Full Job Description
đź“‹ Description
- • The Pharmacy SIU Investigator role at Prime Therapeutics is critical to safeguarding the integrity of pharmacy benefits programs by identifying, investigating, and mitigating fraud, waste, and abuse (FWA) in pharmacy, member, and prescriber activities. This position directly contributes to protecting healthcare resources, ensuring compliance with federal and state regulations, and supporting recovery efforts that reduce unnecessary costs for clients and members.
- • Day-to-day responsibilities include developing investigative plans based on data mining and alerts, gathering and reviewing evidence such as invoices, pharmacy records, licensing documents, and proof of delivery; conducting interviews and background checks; evaluating the validity of suspected FWA cases; ensuring all investigative actions comply with legal and evidentiary standards; preparing detailed reports for leadership, internal committees, or law enforcement referral; recommending process improvements to audit and SIU teams; and coordinating with client SIUs, regulatory bodies, or law enforcement when necessary.
- • The SIU team operates within Prime Therapeutics’ Special Investigations Unit, a dedicated function focused on proactive detection and resolution of healthcare fraud across the PBM landscape. The team collaborates cross-functionally with analytics, legal, pharmacy operations, and client partners, leveraging specialized knowledge of pharmacy claims and healthcare systems to drive impact.
- • In this role, the investigator will develop advanced skills in healthcare fraud detection, forensic evidence analysis, regulatory compliance, and investigative reporting. There is strong potential to grow into senior investigative or leadership positions within SIU, gain expertise in healthcare data systems like RxClaims and JUDI, and earn recognized credentials such as CFE or AHFI while contributing to meaningful cost savings and program integrity.
🎯 Requirements
- • Bachelor’s degree in Criminal Justice, Healthcare, or a related field, or equivalent combination of education and relevant work experience; high school diploma or GED required
- • Minimum of 2 years of work experience in investigation, audit, healthcare, or legal environments
- • Must be eligible to work in the United States without the need for visa sponsorship
🏖️ Benefits
- • Competitive salary range of $59,000.00 to $94,000.00 based on experience and skills
- • Access to comprehensive benefits including health, dental, vision, and wellness programs via Prime Therapeutics’ Benefits Page
- • Support for professional development, including encouragement to pursue certifications such as Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)
- • Remote work flexibility enabling a balanced work-life arrangement from home
- • Opportunity to work with specialized pharmacy claims systems like RxClaims and JUDI, building niche expertise in healthcare data analysis
- • Exposure to cross-functional collaboration with law enforcement, regulatory agencies, and internal stakeholders, enhancing professional network and impact
Skills & Technologies
Remote
Degree Required
About Prime Therapeutics LLC
Prime Therapeutics LLC is a pharmacy benefit management company founded in 1989 and headquartered in Eagan, Minnesota. It administers prescription drug plans on behalf of health plans, employers, and government programs, processing claims, negotiating rebates, managing formularies, and operating specialty pharmacies. Owned by a consortium of Blue Cross and Blue Shield plans, the company serves over 40 million members nationwide while focusing on cost control, clinical outcomes, and member safety.
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