Job Description

A bit about this role:

The Pharmacy Fraud Program Manager is a member of the Special Investigations Unit responsible for detecting, validating, and investigating suspected fraudulent activity within the pharmacy benefit - including prescribing, dispensing, and pharmacy claims activity - across a wide range of internal and external data sources. This role centers on rigorous data validation - reconciling, cross-referencing, and stress-testing information drawn from numerous systems to confirm accuracy, surface inconsistencies, and build defensible investigative findings.

The ideal candidate pairs a deeply inquisitive, investigative mindset with strong analytical discipline and brings genuine pharmacy depth: fluency with pharmacy claims data and pharmacy benefit operations, including NCPDP claim fields, NDCs, quantity and days supply logic, formulary and prior authorization concepts, and prescriber and pharmacy identifiers (NPI, DEA, state license), together with a working knowledge of the regulatory framework governing pharmacy fraud, waste, and abuse.

They are fluent in recognizing pharmacy fraud triggers and red flags - prescribing and dispensing outliers, controlled substance and overutilization patterns, and pharmacy billing schemes - and they actively leverage AI-assisted detection and validation tools to scale their analysis, prioritize cases, and reduce false positives. This person is comfortable asking hard questions, following the data wherever it leads, and translating complex findings into clear, actionable conclusions.

In addition to the core responsibilities of the Fraud Program Manager role, this position serves as the primary owner of the CFWA relationship with our pharmacy benefit manager, coordinating referrals, reporting, and oversight activities between the organization and CVS. This person will work side by side with the Fraud Program Manager on overall fraud detection and scheme identification.

Your responsibilities and impact will include:

CFWA Relationship Management - CVS

• Serve as the primary point of contact and relationship owner for the CFWA program with CVS, managing day-to-day coordination, escalations, and information exchange.
• Manage the intake, routing, and disposition of CFWA referrals to and from CVS, tracking each referral through resolution and ensuring turnaround times and documentation standards are met.
• Lead recurring CFWA governance touchpoints (e.g., joint operating and workgroup meetings), setting agendas, tracking action items, and driving issues to closure.
• Review CVS-provided FWA reporting, investigative summaries, audit results, and recovery activity for completeness, accuracy, and consistency with source claims data; challenge findings that are not supported by the data.
• Monitor CVS performance against contractual, delegated, and regulatory FWA obligations; identify gaps, request corrective action, and escalate deficiencies to compliance and leadership.
• Track pharmacy-level actions performed by CVS under the PBM agreement - including pharmacy audits, prepayment review, claim edits, recoveries, and network termination - confirming that agreed actions were taken and applied correctly, and escalating where they were not.

Data Validation & Source Reconciliation

• Validate, reconcile, and cross-reference data drawn from numerous and disparate sources - pharmacy and medical claims systems, PBM data feeds, prior authorization and rejected-claim data, eligibility and enrollment systems, prescriber and pharmacy provider files, third-party databases, public records, watchlists, internal applications, and external vendor feeds.
• Identify discrepancies, anomalies, and inconsistencies across data sets - including NDC, quantity, days supply, DAW, prescriber NPI, DEA number, and dispensing pharmacy mismatches - and determine whether they indicate error, manipulation, or fraud.
• Establish and maintain data integrity standards for investigations, ensuring findings are accurate, complete, and defensible.
• Trace data lineage across internal systems and PBM-supplied files, corroborating information against authoritative sources to confirm or refute investigative hypotheses.

AI-Assisted Detection & Validation

• Use AI- and machine learning-driven detection tools to flag suspicious patterns, score risk, and surface high-priority cases for review.
• Validate AI-generated alerts and model outputs against source claims and clinical data, distinguishing genuine fraud indicators from false positives, data artifacts, and legitimate clinical variation.
• Provide structured feedback to analytics, vendor, and PBM partners to improve model accuracy, tuning, and rule logic over time.
• Stay current on emerging AI-enabled fraud schemes (e.g., synthetic identities, deepfakes, generated prescriptions or prior authorization documentation, fraudulent e-prescribing credentials) and adapt detection approaches accordingly.

Pharmacy Fraud Detection, Triggers & Red Flags

• Apply deep knowledge of pharmacy fraud triggers, red flags, and typologies - including prescribing and dispensing patterns - to proactively identify suspicious activity before it escalates.
• 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

• Conduct thorough data validation into suspected fraudulent activity, documenting methodology, findings, and conclusions.
• Maintain accurate, audit-ready case records in the case management system.
• Prepare clear written summaries and present findings to leadership, business partners, legal, and, when appropriate, law enforcement or regulatory bodies.

Collaboration & Mentorship

• Partner with claims, payment integrity, underwriting, compliance, legal, and data teams - as well as pharmacy operations and clinical and pharmacy services - to share intelligence and strengthen controls.
• Work and collaborate 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.

Required skills and experience:

• 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.

Desired skills and experience:

• 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 working with data visualization tools, or analytical querying of large data sets.

#LI-Remote

Salary range: $73,000 - $130,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• 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; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.