Case Development Specialist

Location: Remote (For Non-Local) or Hybrid (Local to Denver or NYC area)

Position Summary:

The Case Development Specialist supports both the Pharmacy Audit and the FWA investigation teams by ensuring that all cases are accurately initiated, risk-assessed, and prioritized according to established guidelines. This role serves as the operation backbone for the case intake, triage, and tracking process, verifying data integrity, performing initial analysis, and supporting case documentation from intake through closure.

The Specialist ensures smooth operational flow from case intake through closure, maintaining organized files, supporting data validation, and preparing materials needed for auditors, investigators, and reporting requirements.

Position Responsibilities:

• Enter and track new cases for both Pharmacy Audit and FWA Investigation teams.
• Complete and document risk scores prior to case opening to determine priority level.
• Review incoming referrals for completeness and data accuracy.
• Maintain all cases files and supporting documentation in accordance with SIU standards.
• Prepare case information materials and letters for audits, investigations, and reporting.
• Support communication and document flow between teams.
• Track and report case activity, ensuring deadlines and quality standards are met.
• Enter, track and identify cases involving potential billing issues or referrals from members or providers.
• Track cases by documenting the timeline, interactions between internal teams and pharmacy, and escalating to Pharmacy Audit or FWA Investigation team as needed.
• Assess risk score using judgement and discretion.
• Analyze claims, prior authorization, and patient data to find patterns of abnormal utilization or fraud.
• Responsible for adherence to the Capital Rx Code of Conduct.

Required Qualifications:

• 2+ years of experience in healthcare, PBM, or insurance (SIU or audit experience preferred).
• Strong organizational and data management skills with attention to detail.
• Proficiency with case management systems and Microsoft Office and Excel.
• Ability to handle confidential and sensitive information.

Preferred Qualifications:

• Associate or bachelor's degree preferred.