Manager, Special Investigations Unit - Pharmacy Investigations

Remote

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 Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single,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 (Use the "Apply for this Job" box below). .

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,…