Director, Special Investigations Unit (SIU)
Capital Rx
Location: Remote (For Non-Local) or Hybrid (Local to NYC area)
Position Summary: The Director, Special Investigations Unit (SIU) will lead Capital Rx’s efforts to detect, investigate, and mitigate fraud, waste, and abuse (FWA) across both pharmacy and medical services. This role provides strategic oversight of all SIU operations, including investigations, pharmacy audits, and compliance initiatives, ensuring adherence to state and federal regulations. The Director will collaborate with internal teams and external stakeholders to safeguard the integrity of Capital Rx’s operations and optimize FWA programs.
Position Responsibilities:
- Accountable for managing the day-to-day activities of the SIU and Pharmacy Audit Team, reporting directly to the Head of Compliance.
- Develop and execute pharmacy and medical audit plans, identifying non-compliance, billing discrepancies, and potential fraud across healthcare networks.
- Establish continuous auditing processes for pharmacy and healthcare services, from analytic design through final reporting.
- Develop recommendations for corrective actions and operational improvements based on audit and investigative findings.
- Ensure compliance with all federal and state regulations, including CMS guidelines, pharmacy audit standards, and anti-FWA requirements.
- Manage external engagements and collaborate with legal, regulatory, and law enforcement agencies on investigations and pharmacy audit findings, where applicable.
- Implement new technologies and tools to improve investigative outcomes and the effectiveness of pharmacy audits.
- Provide leadership on case management, ensuring investigations and audits progress efficiently and in accordance with state and federal requirements.
- Hire, train, and develop the SIU team, including auditors and investigators, promoting continuous learning and professional development.
- Establish and monitor key performance indicators (KPIs) for SIU investigations and audits, reporting metrics and outcomes to leadership.
- Coordinate and represent the SIU in state and federal regulatory meetings, industry forums, and legal proceedings as needed.
- Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
Minimum Qualifications:
- Bachelor's degree in criminal justice, finance, healthcare administration, or a related field; master's degree preferred; and/or
- 10+ years of experience managing healthcare investigations, pharmacy audits, and FWA programs, with at least 5 years in a leadership role.
- Certification such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified in Healthcare Compliance (CHC), or Certified Pharmacy Auditor (CPA).
- Comprehensive knowledge of pharmacy claims processing, and reimbursement models.
- Expertise in CMS regulations, healthcare fraud statutes (such as FCA, AKS), and Fair Audit laws.
- Strong data analysis skills with proficiency in Excel, Tableau, or similar tools to support investigations and audits.
- Excellent communication and interpersonal skills, with the ability to work collaboratively across departments and with external partners.
- Strong project management skills, with the ability to manage multiple priorities in a fast-paced environment.
Preferred Qualifications:
- Experience working with pharmacy benefit managers (PBMs), health plans, or other healthcare organizations.
- Knowledge of medical claims processing and reimbursement models.
- Knowledge of HIPAA, data privacy, and security protocols related to FWA investigations and audits.
- Experience collaborating with law enforcement agencies and participating in regulatory audits or legal proceedings.
Base Salary: $125,000 - $145,000
Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
About Capital Rx
Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy 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 pharmacy 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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