Case Development Specialist

Location: Hybrid (Local to NYC, Denver or Charlotte areas)

Position Summary

The Case Development Specialist provides analytical and operational support to the Special Investigations Unit (SIU), partnering with both the Pharmacy Audit and Fraud, Waste and Abuse (FWA) Investigation teams, with a primary focus on Pharmacy Audit operations. This position supports audit and investigative activities by evaluating incoming referrals, conducting risk-based case assessments, performing FWA tip triage, developing case files, analyzing data, and producing reports used to support audit, investigative, compliance, and program integrity initiatives.

The Case Development Specialist serves as a key resource in identifying, organizing, and evaluating information necessary to support audit and investigative reviews. Working closely with Pharmacy Auditors, FWA Investigators, Compliance, Legal, Finance, and other business partners, this position helps ensure accurate case development, consistent application of departmental processes, effective workload management, and timely reporting of audit and FWA-related activities.

Position Responsibilities:

• Receive, review, organize, and maintain documentation submitted by pharmacies and other external parties in support of audit and investigative activities.
• Review, assess, and triage incoming FWA referrals, allegations, complaints, audit leads, and tips to support case prioritization and workflow assignment.
• Complete intake reviews, risk scoring activities, and preliminary case assessments using claims, pharmacy, provider, member, and operational data.
• Create, maintain, and monitor audit and investigation case files within department case management systems, ensuring accurate and complete documentation.
• Perform data validation, research, and analysis to identify utilization trends, billing anomalies, documentation concerns, and potential indicators of fraud, waste, abuse, or audit discrepancies.
• Develop, maintain, and analyze reports, dashboards, case inventories, and tracking tools that support FWA investigations, pharmacy audits, and operational monitoring.
• Monitor documentation requests, response timelines, case milestones, and workload metrics to support timely progression of audit and investigative activities.
• Collaborate with Pharmacy Auditors, FWA Investigators, Compliance, Legal, Finance, and other internal stakeholders to support case development, reporting needs, and operational initiatives.
• Analyze audit and investigation outcomes to identify recurring trends, emerging risks, and opportunities to strengthen program integrity and operational effectiveness.
• Ensure case records, reports, and supporting materials are maintained in accordance with company policies, regulatory requirements, and confidentiality standards.
• Support departmental initiatives focused on improving reporting capabilities, case tracking methodologies, workflow efficiency, and audit and investigative processes.

Required Qualifications

• High school diploma or equivalent required.
• Associate's degree or relevant healthcare, pharmacy, compliance, insurance, or investigative experience preferred.
• Experience in an administrative, healthcare, PBM, insurance, pharmacy, compliance, audit, investigative, or related environment preferred.
• Strong organizational skills with exceptional attention to detail and accuracy.
• Ability to manage documentation, maintain accurate records, and follow established processes and procedures.
• Ability to prioritize competing responsibilities, manage deadlines, and handle multiple assignments simultaneously.
• Strong written, verbal, and interpersonal communication skills, including professional telephone communication with pharmacies and external stakeholders.
• Proficiency in Microsoft Office applications, including Outlook, Excel, Word, and Teams.
• Experience with case management systems, workflow tracking tools, or document management platforms preferred.
• Ability to maintain confidentiality and appropriately handle sensitive or protected information.
• Ability to work independently while collaborating effectively with cross-functional teams.
• Strong problem-solving skills and the ability to identify and escalate issues appropriately.