Pharmacy Fraud Program Lead – Remote

Devoted; Northern (KY); Hybrid; USD 73,000 - 130,000; Full time

Benefits offered by this job

Total rewards package including health

Stock options for all employees

Employer sponsored health plan

Generous paid time off

Job summary

Devoted Health is seeking a Pharmacy Fraud Program Manager to join our Special Investigations Unit. You will detect, validate, and investigate suspected fraudulent activity within the pharmacy benefit, leveraging data across claims, PBM feeds, and external sources.

You will own the CVS CFWA relationship, coordinate referrals, and drive governance, ensuring timely action and robust documentation. The role requires fluency in pharmacy fraud defenses and strong analytical capabilities.

Qualifications

• Bachelor's degree or equivalent investigative experience.
• Minimum 5+ years in fraud investigation or related field.
• Experience with pharmacy benefit operations and claims data.
• Experience managing vendor or PBM relationships.

Responsibilities

• Serve as primary owner of the CFWA relationship with CVS and manage referrals.
• Validate, reconcile, and cross-reference data from multiple sources.
• Lead governance meetings and monitor performance against obligations.
• Investigate referrals and document findings; present to leadership.
• Mentor junior analysts and contribute to SIU process improvements.

Skills

Fraud investigation

Data validation

Pharmacy claims data

NCPDP claim fields

NDCs

quantity and days supply logic

NPI/DEA/state license knowledge

AI/ML-assisted detection

Case management & reporting

Communication skills

Critical thinking

Education

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

Tools

Case management systems

AI/ML platforms

Analytical tools

Job description

Devoted Health is seeking a Pharmacy Fraud Program Manager to join our Special Investigations Unit. You will detect, validate, and investigate suspected fraudulent activity within the pharmacy benefit, leveraging data across claims, PBM feeds, and external sources.

You will own the CVS CFWA relationship, coordinate referrals, and drive governance, ensuring timely action and robust documentation. The role requires fluency in pharmacy fraud defenses and strong analytical capabilities.