Manager, Special Investigations Unit - Pharmacy Investigations

The posting, as Judi Health wrote it

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.

At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health .

Join Judi Rx in advancing pharmacy benefit integrity through disciplined investigations, regulatory expertise, and data-driven action.

Location: Remote

Role Overview

The Manager, SIU - Pharmacy Investigations is a strategic and hands-on leader with required prior pharmacy investigation experience who is responsible for the effective operation, oversight, and continuous improvement of the pharmacy Fraud, Waste, and Abuse (FWA) investigations program. This role leads complex pharmacy investigations, develops a high-performing team, strengthens investigative standards, and ensures matters are handled consistently, objectively, and in accordance with applicable requirements. The Manager serves as a trusted advisor to leadership, clients, Compliance, Legal, Audit, Network, Clinical, Data, and other business partners while maintaining the independence and confidentiality expected of an SIU function.

What You Will Lead

• 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, procedu

[…]
ion, HCAFA, or another relevant investigation, compliance, or pharmacy credential required; multiple relevant credentials preferred.

• Technology: Proficiency with case management systems, claims analytics, research tools, Microsoft Office, and data visualization or reporting platforms.

Success in This Role

• 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.

Remote, US Salary Range
$115,600 — $144,500 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy .