Pharmacy Fraud Program Manager

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $73k - $130k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Program Manager

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• Detect, validate, and investigate suspected fraudulent activity within the pharmacy benefit across prescribing, dispensing, and pharmacy claims activity • Serve as primary point of contact and relationship owner for the CFWA program with CVS • Manage intake, routing, disposition, tracking, and resolution of CFWA referrals to and from CVS • Lead recurring CFWA governance touchpoints, track action items, and drive issues to closure • Review CVS FWA reporting, investigative summaries, audit results, and recovery activity for completeness, accuracy, and consistency with source claims data • Monitor CVS performance against contractual, delegated, and regulatory FWA obligations; identify gaps and escalate deficiencies • Track pharmacy-level actions including audits, prepayment review, claim edits, recoveries, and network termination • Validate, reconcile, and cross-reference data from pharmacy and medical claims, PBM feeds, prior authorization and rejected-claim data, eligibility systems, provider files, databases, public records, watchlists, and vendor feeds • Identify discrepancies and determine whether they indicate error, manipulation, or fraud • Establish and maintain data integrity standards and trace data lineage across systems and PBM-supplied files • Use AI- and machine learning-driven detection tools to flag suspicious patterns, score risk, and prioritize cases • Validate AI-generated alerts and model outputs against source claims and clinical data • Provide feedback to analytics, vendor, and PBM partners to improve model accuracy and rule logic • Monitor emerging AI-enabled fraud schemes and adapt detection approaches • Apply pharmacy fraud triggers, red flags, and typologies to identify suspicious activity • Develop, refine, and document indicators and detection criteria • Investigate referrals and self-sourced leads and build evidence-supported case referrals • Document investigative methodology, findings, and conclusions • Maintain accurate, audit-ready case records • Prepare written summaries and present findings to leadership, business partners, legal, law enforcement, or regulatory bodies • Partner with claims, payment integrity, underwriting, compliance, legal, data, pharmacy operations, and clinical and pharmacy services teams • Collaborate with the Fraud Program Manager on fraud detection and scheme identification • Mentor junior analysts on data validation, investigative methodology, and red-flag recognition • Contribute to continuous improvement of SIU processes, tools, and detection capabilities

🎯 Requirements

• Bachelor's degree in Criminal Justice, Finance, Data Analytics, Health Administration, Pharmacy, Business, or a related field — or equivalent investigative experience • 5+ years of experience in fraud investigation, financial crime, pharmacy benefit or claims analysis, or a closely related field, ideally within an SIU or comparable environment • Demonstrated experience with pharmacy claims data and pharmacy benefit operations, including familiarity with NCPDP claim fields, NDCs, formulary and prior authorization concepts, and prescriber/pharmacy identifiers (NPI, DEA, state license) • Demonstrated experience validating and reconciling data across multiple, disparate systems and sources • Experience managing or supporting a vendor, PBM, or delegated-entity relationship, including referral coordination, reporting review, and performance follow-up • Strong working knowledge of pharmacy fraud triggers, red flags, and common fraud schemes, and of the regulatory framework governing pharmacy FWA • Hands-on experience using analytical, detection, or case management tools, including AI/ML-assisted detection platforms • Excellent analytical, critical-thinking, and problem-solving skills, with a naturally inquisitive and skeptical approach • Strong written and verbal communication skills, with the ability to present complex findings clearly and concisely • Professional certification such as CFE (Certified Fraud Examiner), CFCS, AFE, AHFI, CPhT, or equivalent (desired) • Direct experience with CVS/Caremark data, reporting, or FWA processes (desired) • Experience with controlled substance monitoring, opioid overutilization programs, or PDMP data (desired) • Experience working with data visualization tools, or analytical querying of large data sets (desired)

🏖️ Benefits

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • Parental leave program • 401K program