AI-Powered Pharmacy Fraud Investigator

Devoted Health Services, Inc; Waltham (MA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Health, dental & vision benefits

Stock options

401K with company contribution

Parental leave

Job summary

Devoted Health is seeking a Pharmacy Fraud Program Manager within the Special Investigations Unit. You will own the CFWA relationship with CVS, validate and reconcile data from pharmacy claims and PBM feeds, and use AI-assisted tools to prioritize and investigate suspected fraud.

You will collaborate across claims, compliance, legal, and analytics to strengthen controls and produce clear findings. You will bring deep pharmacy depth, experience with NCPDP/NDC data, and a proactive, questioning

Qualifications

• Bachelor's degree or equivalent investigative experience in a related field.
• 5+ years in fraud investigation, financial crime, pharmacy benefit or claims analysis, SIU or similar.
• Strong pharmacy claims data knowledge including NCPDP, NDCs, formulary, prior authorization, NPI/DEA/state licenses.

Responsibilities

• CFWA relationship management with CVS including referrals, reporting, governance meetings.
• Validate, reconcile, and cross-reference data from multiple sources.
• Leverage AI/ML tools to flag patterns and prioritize cases.
• Identify fraud triggers and red flags in pharmacy prescribing/dispensing.
• Create complete case referrals with validated evidence for leadership and regulators.
• Mentor junior analysts and improve SIU processes and tools.

Skills

Fraud investigation

Pharmacy data analysis

NCPDP data familiarity

NDCs knowledge

Prescriber/Pharmacy identifiers

AI/ML detection tools

Data reconciliation

Stakeholder communication

Education

Bachelor's degree in Criminal Justice, Finance, Data Analytics, Health Administration, Pharmacy, Business, or related field

Tools

Case management tools

AI/ML detection platforms

Job description

Devoted Health is seeking a Pharmacy Fraud Program Manager within the Special Investigations Unit. You will own the CFWA relationship with CVS, validate and reconcile data from pharmacy claims and PBM feeds, and use AI-assisted tools to prioritize and investigate suspected fraud.

You will collaborate across claims, compliance, legal, and analytics to strengthen controls and produce clear findings. You will bring deep pharmacy depth, experience with NCPDP/NDC data, and a proactive, questioning