Prime Therapeutics LLC Medical Coding Analyst in Eagan, Minnesota
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
Medical Coding AnalystJob Description
The Fraud, Waste and Abuse (FWA) Medical Coding Analyst is responsible for analyzing data and providing information to the Pharmacy Audit Operations and Special Investigations Unit (SIU) teams to support the prevention and detection of Fraud, Waste and Abuse (FWA). This position aids Pharmacy Audit by triaging identified issues to the appropriate party and identifying trends that may influence new, or changes to existing processes.
Review claim and audit information to identify suspected of Fraud, Waste, and Abuse (FWA)
Analyze information contained in pharmacy claims processing data (e.g., claims history, provider files) and medical claims to determine provider billing patterns; identify trends and compare observations to standard or expected billing patterns for Prime’s Network Pharmacies; if potential FWA billing practices are identified, notify Prime’s SIU leadership to determine appropriate action
Develop and maintain knowledge of the company's business, industry and regulatory environments; ensure general understanding of FWA policies and state and federal regulations related to healthcare FWA
Evaluate business processes within Pharmacy Audit Operations or SIU to identify enhancement or improvement opportunities that impact fraud case selection; collaborate with department staff, the training and QA team, and department leadership to develop and implement new or enhanced practices
Proactively identify instances of potential FWA and continuously improve identification techniques through data analysis using a variety of analytics and system tools
Use knowledge of heath care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data and other sources
Track analysis activities to support broader reporting efforts within the department; may participate in the development of standard client or internal reporting in support of FWA initiatives
Other duties as assigned
Required Minimum Qualifications:
Bachelor’s degree in Business, Criminal Justice Healthcare or related area of study, or equivalent combination of education and relevant work experience, HS diploma or GED is required
2 years of fraud investigation, analytics or audit experience
Must be eligible to work in the United States without need for work visa or residency sponsorship.
Excellent verbal and written communication skills
Skill and understanding of point of sale and on-line pharmacy claims processing environment
Ability to build a collaborative team and work effectively across functions, disciplines, and or/other groups
Demonstrated ability to problem solve through complex situations
Ability to think critically, problem solve and make decisions while anticipating the broad impact of decisions
Intermediate proficiency with MS Office suites such as Access, Excel, PowerPoint, and Word
PBM, healthcare, or medical claims experience
ICD 10 (and ICD 9), HCPCS and CPT, (MS-)DRGS, CC and MCC, and/or APCS healthcare code experience
Experience with SAS, SQL, and/or data visualization tools
Certified Fraud Examiners (CFE) designation or Accredited Health Care Fraud Investigator (AHFI) certification
Experience with data analysis techniques
Minimum Physical Job Requirements:
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
- Reports to Manager in the Pharmacy Audit and FWA department
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions.
Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.
If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at 1.866.469.1257 or email Careers@primetherapeutics.com.