Pharmacy Fraud Program Manager
Core
Detect, validate, and investigate suspected fraudulent activity within pharmacy benefit operations, including prescribing, dispensing, and claims activity, while managing the relationship with a Pharmacy Benefit Manager (CVS).
Role type
Senior IC fraud program manager (pharmacy benefit)
Builds
Defensible investigative findings, validated case referrals, and oversight of PBM performance
Domain
Healthcare + Pharmacy Benefit Management + Financial Crime
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
pharmacy claims data analysis, NCPDP claim fields, NDC logic, formulary and prior authorization concepts, prescriber/pharmacy identifier validation (NPI, DEA), data reconciliation across disparate systems, AI/ML detection tool validation, regulatory framework knowledge (FWA), case management, relationship management with PBMs
Preferred skills
CFE/CFCS/AFE/AHFI/CPhT certification, experience with CVS/Caremark data and reporting
Technologies
AI/ML-assisted detection platforms, case management systems, pharmacy claims systems, PBM data feeds
Responsibilities
Manage intake, routing, and disposition of CFWA referrals to/from CVS; validate and reconcile data from multiple sources to identify discrepancies; use AI tools to flag suspicious patterns and validate alerts; investigate suspected fraud and build evidence-based case referrals; monitor PBM performance against contractual and regulatory obligations; mentor junior analysts on data validation and red-flag recognition
Seniority
Senior, hands-on IC
