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Salary: USD 73,000 - 130,000 / annual
Devoted Health seeks a Pharmacy Fraud Program Manager to join the Special Investigations Unit, responsible for detecting, validating, and investigating suspected fraudulent activity within the pharmacy benefit. This role combines rigorous data validation with deep pharmacy domain expertise to identify and investigate fraud across prescribing, dispensing, and pharmacy claims activity.
Key responsibilities include:
**CFWA Relationship Management (CVS):** Serve as primary point of contact for the CFWA program with CVS, managing day-to-day coordination, escalations, and information exchange. Manage intake, routing, and disposition of CFWA referrals, tracking each through resolution while ensuring turnaround times and documentation standards are met. Lead recurring governance touchpoints, set agendas, track action items, and drive issues to closure. Review CVS-provided FWA reporting, investigative summaries, and audit results for completeness and accuracy; challenge unsupported findings. Monitor CVS performance against contractual and regulatory FWA obligations, identify gaps, and escalate deficiencies. Track pharmacy-level actions performed by CVS (audits, prepayment review, claim edits, recoveries, terminations), confirming correct application.
**Data Validation & Source Reconciliation:** Validate and reconcile data from numerous sources—pharmacy and medical claims systems, PBM data feeds, prior authorization data, eligibility systems, prescriber/pharmacy files, third-party databases, and external vendor feeds. Identify discrepancies and anomalies (NDC, quantity, days supply, DAW, prescriber NPI, DEA number, dispensing pharmacy mismatches) and determine whether they indicate error, manipulation, or fraud. Establish and maintain data integrity standards for investigations. Trace data lineage across internal systems and PBM-supplied files, corroborating information against authoritative sources.
**AI-Assisted Detection & Validation:** Use AI and machine learning detection tools to flag suspicious patterns, score risk, and surface high-priority cases. Validate AI-generated alerts against source claims and clinical data, distinguishing genuine fraud indicators from false positives and legitimate variation. Provide structured feedback to analytics, vendor, and PBM partners to improve model accuracy. Stay current on emerging AI-enabled fraud schemes (synthetic identities, deepfakes, generated prescriptions, fraudulent e-prescribing credentials).
**Pharmacy Fraud Detection:** Apply deep knowledge of pharmacy fraud triggers, red flags, and typologies—including prescribing and dispensing patterns—to proactively identify suspicious activity. Develop, refine, and document indicators and detection criteria based on emerging schemes and investigative learnings. Investigate referrals and self-sourced leads, building complete case referrals supported by validated evidence.
**Case Referrals & Documentation:** Conduct thorough data validation into suspected fraudulent activity, documenting methodology, findings, and conclusions. Maintain accurate, audit-ready case records. Prepare clear written summaries and present findings to leadership, business partners, legal, and law enforcement/regulatory bodies as appropriate.
**Collaboration & Mentorship:** Partner with claims, payment integrity, underwriting, compliance, legal, data, pharmacy operations, clinical, and pharmacy services teams to share intelligence and strengthen controls. Work with the Fraud Program Manager on overall fraud detection and scheme identification. Mentor junior analysts on data validation techniques, 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 related field—or equivalent investigative experience
- 5+ years of experience in fraud investigation, financial crime, pharmacy benefit or claims analysis, or 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 ability to present complex findings clearly and concisely
**Desired:**
- Professional certification such as CFE (Certified Fraud Examiner), CFCS, AFE, AHFI, CPhT, or equivalent
- Direct experience with CVS/Caremark data, reporting, or FWA processes
- Experience with controlled substance monitoring, opioid overutilization programs, or PDMP data
- Experience with data visualization tools or analytical querying of large data sets
