Medicare Part D Investigator & Program Integrity Lead

RELI Group, Inc.; United States; On-site; USD 90,000 - 110,000; Full time

Job summary

RELI Group, Inc. is recruiting a Part D Sr Investigator to support integrity and effectiveness of federal healthcare programs through investigations, compliance oversight, and risk assessment.

The role reviews pharmacies, dispensers, and manufacturers; develops investigative strategies and compliance processes; analyzes data and evidence; and produces actionable findings. Collaboration with CMS and OIG is expected.

Qualifications

• Bachelor's degree plus 5 years of relevant professional experience.
• Associates degree plus 8 years of relevant professional experience.
• High school diploma plus 9 years of relevant professional experience.
• Demonstrated knowledge of Medicare Part D, drug pricing, manufacturer rebate structures, or government pricing programs.
• Strong analytical and investigative skills.
• Knowledge of federal healthcare regulations, especially pricing and compliance.
• Excellent written and verbal communication.
• Strong project management skills.
• Experience using case management systems, e-discovery tools, and data analytics platforms.

Responsibilities

• Support the Investigation Lead with functions of the task order, including the review of dispensers, pharmacies, and manufacturers' practices to ensure adherence to Negotiation Program requirements.
• Assist in the development of all necessary compliance requirements to inform compliance, investigations, reporting, and market surveillance activities.
• Assist in developing necessary investigation processes to ensure implementation of timely, thorough, and unbiased investigations.
• Assist in developing an investigation strategy and approach to ensure investigations are completed in accordance with program timelines and quality standards.
• Identify and assess potential risks or violations through data analysis, stakeholder interviews, audits, and tips received through oversight channels.
• Assist with intake, triage, and prioritization of investigative matters aligned with CMS compliance objectives.
• Collaborate with data analysts, auditors, compliance officers, legal experts, and other stakeholders to collect and assess evidence.
• Draft detailed investigation plans, memoranda, and final reports with actionable findings and recommendations.
• Coordinate with CMS, OIG, and other federal oversight bodies on escalated matters requiring enforcement or corrective action.
• Maintain a secure, documented chain of evidence throughout each case in compliance with federal guidelines.
• Establish and refine investigation protocols, SOPs, and escalation procedures in coordination with the complaint/dispute and auditing teams.
• Mentor junior staff and serve as subject matter expert (SME) related to investigative techniques and healthcare program integrity.

Skills

Medicare Part D knowledge

Data analysis

Investigative skills

Regulatory compliance

Communication/writing

Project management

E-discovery tools

Data analytics platforms

Education

Bachelor's degree + 5 years experience

Associates degree + 8 years experience

High school diploma + 9 years experience

Tools

Case management systems

Data analytics platforms

Job description

RELI Group, Inc. is recruiting a Part D Sr Investigator to support integrity and effectiveness of federal healthcare programs through investigations, compliance oversight, and risk assessment.

The role reviews pharmacies, dispensers, and manufacturers; develops investigative strategies and compliance processes; analyzes data and evidence; and produces actionable findings. Collaboration with CMS and OIG is expected.