Pharmacy Fraud Program Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Identify, validate, and investigate potential fraudulent activities within the pharmacy benefits related to prescribing, dispensing, and pharmacy claims.

• Act as the primary contact and relationship manager for the CFWA program with CVS.

• Oversee the intake, routing, disposition, tracking, and resolution of CFWA referrals involving CVS.

• Facilitate regular CFWA governance meetings, monitor action items, and ensure issues are resolved.

• Assess CVS FWA reports, investigative summaries, audit results, and recovery efforts for thoroughness, accuracy, and alignment with source claims data.

• Track CVS performance regarding contractual, delegated, and regulatory FWA obligations; identify shortcomings and escalate issues as necessary.

• Monitor pharmacy-level actions such as audits, prepayment reviews, claim edits, recoveries, and network terminations.

• Validate, reconcile, and cross-check data from pharmacy and medical claims, PBM feeds, prior authorization and rejected claims data, eligibility systems, provider files, databases, public records, watchlists, and vendor feeds.

• Detect discrepancies and ascertain whether they point to errors, manipulation, or fraudulent activities.

• Establish and uphold data integrity standards while tracing data lineage across systems and PBM-supplied files.

• Utilize AI- and machine learning-driven detection tools to identify suspicious patterns, assess risk, and prioritize cases.

• Confirm AI-generated alerts and model outputs against source claims and clinical data.

• Provide insights to analytics, vendor, and PBM partners to enhance model accuracy and rule logic.

• Stay updated on emerging AI-enabled fraud schemes and adjust detection strategies accordingly.

• Implement pharmacy fraud triggers, red flags, and typologies to recognize suspicious activities.

• Develop, enhance, and document indicators and detection criteria.

• Investigate referrals and self-sourced leads, compiling evidence-supported case referrals.

• Record investigative methodologies, findings, and conclusions.

• Maintain precise, audit-ready case records.

• Prepare written summaries and present findings to leadership, business partners, legal entities, law enforcement, or regulatory bodies.

• Collaborate with claims, payment integrity, underwriting, compliance, legal, data, pharmacy operations, and clinical and pharmacy services teams.

• Work together with the Fraud Program Manager on fraud detection and scheme identification.

• Guide junior analysts on data validation, investigative techniques, and identifying red flags.

• Contribute to the ongoing enhancement of SIU processes, tools, and detection capabilities.

⛳️ Requirements

• Bachelor’s degree in Criminal Justice, Finance, Data Analytics, Health Administration, Pharmacy, Business, or a related field — or equivalent investigative experience.

• Over 5 years of experience in fraud investigation, financial crime, pharmacy benefit or claims analysis, or a closely related field, preferably within an SIU or similar environment.

• Proven experience with pharmacy claims data and pharmacy benefit operations, including knowledge of NCPDP claim fields, NDCs, formulary and prior authorization concepts, and prescriber/pharmacy identifiers (NPI, DEA, state license).

• Demonstrated ability to validate and reconcile data across various, disparate systems and sources.

• Experience in managing or supporting vendor, PBM, or delegated-entity relationships, including referral coordination, reporting review, and performance follow-up.

• Strong understanding of pharmacy fraud triggers, red flags, and prevalent fraud schemes, as well as the regulatory framework governing pharmacy FWA.

• Hands-on experience with analytical, detection, or case management tools, including AI/ML-assisted detection platforms.

• Excellent analytical, critical-thinking, and problem-solving abilities, with a naturally inquisitive and skeptical mindset.

• Strong written and verbal communication skills, capable of presenting complex findings in a clear and concise manner.

• Professional certification such as CFE (Certified Fraud Examiner), CFCS, AFE, AHFI, CPhT, or equivalent (preferred).

• Direct experience with CVS/Caremark data, reporting, or FWA processes (preferred).

• Experience in controlled substance monitoring, opioid overutilization programs, or PDMP data (preferred).

• Familiarity with data visualization tools, or analytical querying of large data sets (preferred).

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director and above.

• Parental leave program.

• 401K program.