Pharma FWA Investigations Manager

Highmark Health; Pittsburgh (Allegheny County); On-site; USD 120,000 - 180,000; Full time

Job summary

Highmark Health is seeking a senior leader for the Financial Investigations & Provider Review (FIPR) unit, with emphasis on pharmaceutical cases. Lead a team focused on fraud, waste and abuse detection, recovery of overpayments, and Medicare compliance matters.

The role requires strong analytic and leadership skills, with experience in auditing, pharmacy management, and regulatory interactions with CMS/NCQA/HEDIS.

Qualifications

• Bachelor’s degree in Pharmacy required; Master’s preferred.
• 5 years of auditing or provider reimbursement experience in healthcare.
• 3 years of clinical pharmacy management experience including drug use review.
• 1 year working with CMS/NCQA/HEDIS/DOH or similar regulatory entities.

Responsibilities

• Lead and manage the FIPR department daily operations.
• Hire, coach, and develop staff; manage performance and productivity.
• Develop case strategies and coordinate with audit vendors and law enforcement as needed.
• Present provider/network cases to Medical Review Committee; collaborate with legal counsel.

Skills

Leadership

FWA Knowledge

Team Management

Regulatory Compliance

Pharmacy background

Education

Bachelor’s degree in Pharmacy

Tools

Audit Software

Pharmacy Information Systems

Job description

Highmark Health is seeking a senior leader for the Financial Investigations & Provider Review (FIPR) unit, with emphasis on pharmaceutical cases. Lead a team focused on fraud, waste and abuse detection, recovery of overpayments, and Medicare compliance matters.

The role requires strong analytic and leadership skills, with experience in auditing, pharmacy management, and regulatory interactions with CMS/NCQA/HEDIS.