Manager, Special Investigations Unit - Pharmacy Investigations

About the company

The company is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. The company replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single,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, the company helps clients achieve unprecedented operational efficiency and service levels.

At the company, 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 [link for members] .

Join the company 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, 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.

What You Bring

• Experience: At least 5 years of healthcare fraud investigation experience, including direct, substantive experience conducting and leading pharmacy investigations. A pharmacy investigation background is required. Experience must include complex pharmacy case management, pharmacy claims analysis, evidence development, regulatory compliance, and investigative leadership.

• Leadership: Proven experience leading investigators, managing competing priorities, strengthening team performance, and driving complex matters to clear and defensible outcomes.

• Technical Expertise: Strong knowledge of pharmacy claims, PBM operations, healthcare FWA schemes, investigative methods, evidence development, and applicable laws and regulations, including the False Claims Act, Anti-Kickback Statute, and related federal and state requirements.

• Analytical Capability: Demonstrated ability to interpret claims data, identify anomalous patterns, assess risk, connect information across sources, and convert findings into actionable recommendations.

• Communication: Exceptional written, verbal, and presentation skills, including the ability to explain complex investigative matters to executives, clients, regulators, attorneys, and operational partners.

• Judgment: Sound decision-making, objectivity, attention to detail, and the ability to handle confidential, high-risk, and time-sensitive matters with discretion.

• Education: Bachelor's degree in healthcare, criminal justice, compliance, business, data analytics, or a related field, or equivalent relevant experience.

• Certification: AHFI, CFE, pharmacy technician certification, 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 company 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 the company. More details about the company's privacy practices can be found at   [link for members] .