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Manager, Special Investigations Unit - Pharmacy Investigations
Location: Remote
Position Summary:
We are seeking a dynamic and experienced leader to spearhead our Special Investigations Unit (SIU), overseeing our enterprise-wide Fraud, Waste, and Abuse (FWA) program. This is a high-impact, strategic role ideal for a people leader with deep expertise in pharmacy investigations and a passion for protecting healthcare systems from abuse.
As the SIU Manager, you will lead the design, implementation, and continuous improvement of Capital Rx’s FWA program. You’ll combine investigative acumen with data-driven insights to detect and prevent fraudulent activity across pharmacy, prescriber, and member channels. You’ll also serve as a trusted advisor and subject matter expert, collaborating cross-functionally to embed FWA prevention into the fabric of our operations.
Position Responsibilities:
- Build and manage a best-in-class FWA program aligned with federal and state regulations, accreditation standards, and industry best practices.
- Lead complex investigations into potential FWA involving pharmacies, prescribers, and members using advanced analytics and investigative tools.
- Develop and enforce SIU/FWA policies and procedures, ensuring consistency, compliance, and operational excellence.
- Analyze data to identify emerging fraud trends and proactively mitigate risk.
- Prepare and present detailed investigative reports and remediation strategies to executive leadership and to clients.
- Collaborate with internal teams and external stakeholders—including law enforcement and regulatory agencies—to drive resolution and accountability.
- Deliver FWA training and education to internal teams, board members, and enrollees.
- Represent Capital Rx in legal proceedings and testify as needed.
- Foster a culture of compliance, ethics, and continuous improvement across the organization.
- Lead, mentor, and inspire a high-performing investigations team, fostering a culture of accountability, collaboration, and continuous improvement while aligning with Capital Rx’s mission and compliance standards.
- Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
Required Qualifications:
- Experience: Minimum 5 years in health care fraud investigations, preferably pharmacy investigations with a strong track record in fraud detection, regulatory compliance, and investigative leadership.
- Leadership: Proven ability to lead cross-functional teams and manage complex investigative projects.
- Expertise: Deep knowledge of pharmacy investigations, healthcare FWA laws and regulations (e.g., False Claims Act, Anti-Kickback Statute, Stark Law).
- Certifications: AHFI, CFE, Pharmacy Technician, or HCAFA required.
- Education: Bachelor’s degree in healthcare, Criminal Justice, or related field (or equivalent experience).
- Skills: Exceptional analytical, communication, and interpersonal skills. Ability to manage multiple priorities with precision and discretion.
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.
Salary Range
$100,000 - $135,000 USD
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to 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.
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