Pharmacy Fraud Program Manager

A bit about this role: The Pharmacy Fraud Program Manager is a member of the Special Investigations Unit responsible for detecting, validating, and investigating suspected fraudulent activity within the pharmacy benefit — including prescribing, dispensing, and pharmacy claims activity — across a wide range of internal and external data sources. This role centers on rigorous data validation — reconciling, cross-referencing, and stress-testing information drawn from numerous systems to confirm accuracy, surface inconsistencies, and build defensible investigative findings. The ideal candidate pairs a deeply inquisitive, investigative mindset with strong analytical discipline and brings genuine pharmacy depth: fluency with pharmacy claims data and pharmacy benefit operations, including NCPDP claim fields, NDCs, quantity and days supply logic, formulary and prior authorization concepts, and prescriber and pharmacy identifiers (NPI, DEA, state license), together with a working knowledge of the regulatory framework governing pharmacy fraud, waste, and abuse. They are fluent in recognizing pharmacy fraud triggers and red flags — prescribing and dispensing outliers, controlled substance and overutilization patterns, and pharmacy billing schemes — and they actively leverage AI-assisted detection and validation tools to scale their analysis, prioritize cases, and reduce false positives. This person is comfortable asking hard questions, following the data wherever it leads, and translating complex findings into clear, actionable conclusions. In addition to the core responsibilities of the Fraud Program Manager role, this position serves as the primary owner of the CFWA relationship with our pharmacy benefit manager, coordinating referrals, reporting, and oversight activities between the organization and CVS. This person will work side by side with the Fraud Program Manager on overall fraud detection and scheme identification. Your responsibilities and impact will include: CFWA Relationship Management — CVS Serve as the primary point of contact and relationship owner for the CFWA program with CVS, managing day-to-day coordination, escalations, and information exchange. Manage the intake, routing, and disposition of CFWA referrals to and from CVS, tracking each referral through resolution and ensuring turnaround times and documentation standards are met. Lead recurring CFWA governance touchpoints (e.g., joint operating and workgroup meetings), setting agendas, tracking action items, and driving issues to closure. Review CVS-provided FWA reporting, investigative summaries, audit results, and recovery activity for completeness, accuracy, and consistency with source claims data; challenge findings that are not supported by the data. Monitor CVS performance against contractual, delegated, and regulatory FWA obligations; identify gaps, request corrective action, and escalate deficiencies to compliance and leadership. Track pharmacy-level actions performed by CVS under the PBM agreement — including pharmacy audits, prepayment review, claim edits, recoveries, and network termination — confirming that agreed actions were taken and applied correctly, and escalating where they were not. Data Validation & Source Reconciliation Validate, reconcile, and cross-reference data drawn from numerous and disparate sources — pharmacy and medical claims systems, PBM data feeds, prior authorization and rejected-claim data, eligibility and enrollment systems, prescriber and pharmacy provider files, third-party databases, public records, watchlists, internal applications, and external vendor feeds. Identify discrepancies, anomalies, and inconsistencies across data sets — including NDC, quantity, days supply, DAW, prescriber NPI, DEA number, and dispensing pharmacy mismatches — and determine whether they indicate error, manipulation, or fraud. Establish and maintain data integrity standards for investigations, ensuring findings