Remote Pharmacy Fraud Investigator & Data Validator

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

Benefits offered by this job

Health, dental & vision coverage

Paid time off

Stock options

Job summary

Devoted Health seeks a Pharmacy Fraud Program Manager to lead the Special Investigations Unit in detecting, validating, and investigating fraud across pharmacy benefit data sources. The role emphasizes data integrity, cross-system verification, and building defensible investigative findings while coordinating with CVS on CFWA activities.

The ideal candidate has pharmacy depth, familiarity with NCPDP, NDCs, formulary concepts, prior authorization, and prescriber/pharmacy identifiers, plus

Qualifications

• Bachelor's degree in Criminal Justice, Finance, Data Analytics, Health Administration, Pharmacy, Business, or related field, or equivalent investigative experience.
• 5+ years of experience in fraud investigation, financial crime, pharmacy benefit or claims analysis, or related field.

Responsibilities

• CFWA relationship management with CVS, managing referrals, onboarding governance, and ensuring documentation standards.
• Validate, reconcile, and cross-reference data from pharmacy/medical claims, PBM data feeds, prior authorization data, eligibility systems, and external feeds.
• Use AI/ML-driven detection tools to flag patterns, score risk, and prioritize cases; validate model outputs against source data.
• Investigate referrals and self-sourced leads, building complete case referrals with validated evidence.
• Mentor junior analysts and collaborate with claims, underwriting, compliance, legal, and data teams to strengthen controls.

Skills

Pharmacy claims data

NCPDP claim fields

NDCs

Prior authorization concepts

Prescriber/pharmacy identifiers

DEA/state license

AI/ML detection tools

Data validation

Investigation techniques

Analytical thinking

Education

Bachelor's degree in Criminal Justice/Finance/Data Analytics/Health Admin/Pharmacy (or related)

Tools

AI/ML platforms

Case management tools

Job description

Devoted Health seeks a Pharmacy Fraud Program Manager to lead the Special Investigations Unit in detecting, validating, and investigating fraud across pharmacy benefit data sources. The role emphasizes data integrity, cross-system verification, and building defensible investigative findings while coordinating with CVS on CFWA activities.

The ideal candidate has pharmacy depth, familiarity with NCPDP, NDCs, formulary concepts, prior authorization, and prescriber/pharmacy identifiers, plus