Pharmacy Fraud Investigator & Data Validation Lead

Hey Health Tech; Waltham (MA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Health plan

Generous PTO

Monthly mobile stipend

Stock options

Bonus eligibility

Parental leave

401K

Job summary

Devoted Health is seeking a Pharmacy Fraud Program Manager in Waltham, MA to lead fraud detection, validation, and investigation of pharmacy benefit activities. You will manage CVS/CFWA relationships, coordinate referrals, and drive data integrity across multiple systems.

The role requires strong pharmacy knowledge, 5+ years in fraud/claims analysis, and experience with AI-assisted detection tools to surface high-priority cases and guide leadership with clear findings.

Qualifications

• Bachelor's degree or equivalent investigative experience.
• 5+ years in fraud investigation, financial crime, or pharmacy benefit/claims analysis.
• Experience with pharmacy claims data and PBM operations, NCPDP/NDCs/NPI/DEA.
• Ability to validate and reconcile data across multiple systems.
• Experience managing vendor/PBM/delivered-entity relationships.
• Knowledge of pharmacy fraud triggers and regulatory FWA framework.
• Experience with AI/ML detection platforms and data visualization tools.

Responsibilities

• Detect, validate, and investigate suspected pharmacy fraud across prescribing, dispensing, and claims activity.
• Serve as primary owner for CFWA relationship with CVS; coordinate referrals and governance.
• Validate data lineage and ensure data integrity for investigations.
• Leverage AI-assisted detection to prioritize cases and reduce false positives.
• Mentor junior analysts and contribute to SIU process improvements.

Skills

Fraud investigations

Pharmacy claims data

NCPDP claim fields

NDCs

NPI/DEA/state license

AI/ML detection tools

Analytical thinking

Clear written/ verbal communication

Education

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

Tools

Case management tools

Data validation tools

Job description

Devoted Health is seeking a Pharmacy Fraud Program Manager in Waltham, MA to lead fraud detection, validation, and investigation of pharmacy benefit activities. You will manage CVS/CFWA relationships, coordinate referrals, and drive data integrity across multiple systems.

The role requires strong pharmacy knowledge, 5+ years in fraud/claims analysis, and experience with AI-assisted detection tools to surface high-priority cases and guide leadership with clear findings.