Judi Health - Manager, Special Investigations Unit - Pharmacy Investigations

• Lead the pharmacy SIU investigations program, including intake, triage, case assignment, investigative strategy, documentation, escalation, resolution, and closure. • Build and maintain a risk-based investigative framework aligned with applicable federal and state requirements, contractual obligations, accreditation standards, client expectations, and recognized industry practices. • Direct complex investigations involving suspected pharmacy fraud, waste, or abuse, including schemes identified through referrals, analytics, audits, complaints, hotline reports, or other credible sources. • Ensure investigative plans are thorough, impartial, timely, and supported by clear evidence, defensible findings, and complete case documentation. • Use claims data, trend analysis, public records, interviews, supporting documentation, and investigative tools to identify patterns, relationships, emerging schemes, and potential program risk. • Establish quality standards and review controls for case files, investigative reports, evidence retention, corrective action recommendations, referrals, and closure decisions. • Develop, maintain, and enforce SIU policies, procedures, workflows, templates, and service-level expectations to promote consistency, compliance, and operational discipline. • Partner with Legal, Compliance, Pharmacy Audit, Network, Clinical, Payment Integrity, Data Analytics, Finance, and client-facing teams while preserving clear functional boundaries between audit activity and SIU investigations. • Coordinate appropriate internal escalations and external referrals to government agencies, law enforcement, regulators, or other authorized entities, in consultation with Legal and Compliance. • Prepare concise, executive-ready reports and presentations that communicate investigative findings, financial and operational exposure, root causes, recommended actions, and status of significant matters. • Support remediation and risk mitigation efforts, including corrective action, network action, recovery coordination, monitoring, education, control enhancements, and follow-up review, as appropriate. • Develop meaningful program metrics and reporting to assess case volume, timeliness, trends, outcomes, control gaps, referral quality, and program effectiveness. • Monitor emerging pharmacy FWA risks, regulatory developments, enforcement activity, and industry trends; translate developments into practical program enhancements. • Lead FWA education and awareness initiatives for employees, leadership, board members, clients, and other applicable audiences. • Represent the organization in client meetings, audits, regulatory reviews, legal proceedings, and testimony when required and authorized. • Recruit, coach, and retain a high-performing investigations team; set clear expectations, develop staff capability, manage workload, and foster accountability, sound judgment, collaboration, and continuous improvement. • Manage sensitive and confidential information with the highest degree of integrity, professionalism, discretion, and need-to-know access. • Investigations are timely, well-documented, objective, and defensible. • High-risk matters are identified, prioritized, escalated, and resolved appropriately. • Leadership and clients receive clear, accurate, and actionable information. • Program policies, controls, reporting, and team capabilities continue to mature as the business grows. • The SIU operates with independence, integrity, regulatory discipline, and strong cross-functional partnership. • This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, skills, and location of the job.