New Manager, Special Investigations Unit - Pharmacy Investigations

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. 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. 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.