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Capital Rx · 7 hours ago

Case Development Specialist

Denver, NY

Full-time

Hybrid

Entry Level

$43K/yr - $54K/yr

2+ years exp

Judi Health is an enterprise health technology company focused on rebuilding trust in healthcare. The Case Development Specialist supports the Pharmacy Audit and FWA investigation teams by managing case intake, ensuring data integrity, and preparing necessary documentation throughout the case lifecycle.

Hospital & Health Care

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