Case Development Specialist

About Judi Health

Judi Health is a healthcare technology enterprise delivering integrated solutions for employers and health plans, including full-service pharmacy benefit management (PBM) via Judi Rx, comprehensive health benefit management through Judi Health™, and the industry-leading Enterprise Health Platform (EHP) that consolidates claims administration workflows into one secure, scalable system. Our mission is to restore trust in U.S. healthcare by deploying essential infrastructure for optimal care.

Location: Hybrid setup with onsite presence expected in NYC, Denver, or Charlotte areas.

Position Overview

The Case Development Specialist plays a crucial role within the Special Investigations Unit (SIU), providing both operational and analytical assistance primarily to Pharmacy Audit functions while also supporting Fraud, Waste, and Abuse (FWA) investigative efforts. This role involves assessing referrals, conducting risk-focused case analyses, managing case files, analyzing data trends, and generating reports that underpin audits, investigations, compliance, and program integrity.

Key Responsibilities

• Manage and organize documentation submitted by pharmacies and external entities to support audits and investigations.
• Evaluate and triage incoming FWA referrals, complaints, and audit leads to prioritize cases and assign workflows effectively.
• Conduct intake assessments and risk scoring using claims, pharmacy, provider, member, and operational data.
• Create and maintain case files within management systems, ensuring all documentation is accurate and comprehensive.
• Perform data validation and analysis to detect utilization trends, billing irregularities, documentation issues, and potential fraud or audit concerns.
• Generate and review reports and dashboards to track case inventories and support pharmacy audits and FWA investigations.
• Oversee documentation follow-ups, case milestones, and workload metrics to maintain timely audit and investigation progression.
• Collaborate cross-functionally with Pharmacy Auditors, Investigators, Compliance, Legal, Finance, and other stakeholders to facilitate effective case development and reporting.
• Analyze outcomes of audits and investigations to identify trends, risks, and opportunities to improve program integrity and operations.
• Ensure all case materials comply with internal policies, regulations, and confidentiality standards.
• Contribute to initiatives that enhance reporting, case tracking, workflow efficiency, and investigative processes.

Qualifications

• Minimum of a high school diploma or equivalent required; associate’s degree or relevant healthcare, pharmacy, compliance, insurance, or investigative experience preferred.
• Experience in administrative, healthcare, PBM, insurance, pharmacy, compliance, audit, or investigative environments is desirable.
• Excellent organizational skills with meticulous attention to detail.
• Capability to handle documentation management, maintain accurate records, and adhere to established workflows and procedures.
• Ability to prioritize multiple assignments, meet deadlines, and manage competing responsibilities.
• Strong communication skills, both written and oral, including professional telephone interactions with external parties.
• Proficient in Microsoft Office suite (Outlook, Excel, Word, Teams); familiarity with case management and document tracking systems is a plus.
• Ability to maintain confidentiality and manage sensitive information responsibly.
• Self-motivated with strong collaboration skills across different teams.
• Problem-solving aptitude with sound judgment for escalating issues when necessary.

Compensation

Salary ranges by location:

• New York, NY: $64,000 - $80,000
• Denver, CO: $58,400 - $73,000
• Charlotte, NC: $53,200 - $66,500

Additional Information

All employees must comply with the Judi Health Code of Conduct, including the mandatory reporting of non-compliance. This role description is flexible and may be modified by management to align with organizational needs.

Judi Health is an equal opportunity employer, prohibiting discrimination and harassment based on race, color, religion, age, sex, national origin, disability, medical condition, genetic information, veteran status, sexual orientation, gender identity or expression, or any legally protected characteristics.

Applicants consent to the retention of their personal data for future hiring considerations as described in Judi Health's privacy policy.