Remote Pharmacy Fraud & Data Integrity Lead

Devoted Health; Maryland; On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Health, dental and vision plan

Stock options

Bonus eligibility

401K

Parental leave

Paid time off

Job summary

Devoted Health is seeking a Pharmacy Fraud Program Manager to join the Special Investigations Unit. You will detect and investigate suspected fraudulent activity within the pharmacy benefit, leveraging data from multiple systems to surface inconsistencies and craft defensible findings.

The role emphasizes AI-assisted detection, validation of alerts, and collaboration with CVS to manage referrals, reporting, and governance. A strong pharmacy data background is essential.

Qualifications

• 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, ideally within an SIU or comparable environment.
• Demonstrated experience with pharmacy claims data and pharmacy benefit operations, including 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.
• Strong written and verbal communication skills with ability to present complex findings clearly and concisely.

Responsibilities

• CFWA relationship management with CVS: coordination, escalations, and information exchange.
• Validate, reconcile, and cross-reference data from claims, PBM feeds, and enrollment systems.
• Lead governance meetings, agendas, action tracking, and issue resolution.
• Review CVS FWA reporting and ensure findings align with source claims data.
• Mentor analysts and improve SIU processes and detection capabilities.

Skills

Pharmacy fraud detection

Data validation

AI/ML detection

Analytical thinking

Communication

Education

Bachelor's degree or equivalent in related field

Tools

Case management system

Data visualization tools

Job description

Devoted Health is seeking a Pharmacy Fraud Program Manager to join the Special Investigations Unit. You will detect and investigate suspected fraudulent activity within the pharmacy benefit, leveraging data from multiple systems to surface inconsistencies and craft defensible findings.

The role emphasizes AI-assisted detection, validation of alerts, and collaboration with CVS to manage referrals, reporting, and governance. A strong pharmacy data background is essential.