Pharmacy Fraud Manager
Job Summary
The full-time Pharmacy Fraud Manager will be responsible for detecting, validating, and investigating suspected fraudulent activity within pharmacy benefits, leveraging strong analytical skills and pharmacy claims data expertise while working remotely.
Key responsibilities
- Manage the CFWA relationship with CVS, coordinating referrals, reporting, and oversight activities
- Validate and reconcile data from various sources to identify discrepancies and ensure data integrity for investigations
- Utilize AI-assisted detection tools to flag suspicious patterns and validate alerts against source claims data
Required qualifications
- Bachelor's degree in a relevant field or equivalent investigative experience
- 5+ years of experience in fraud investigation or pharmacy benefit analysis
- Demonstrated experience with pharmacy claims data and operations, including familiarity with NCPDP claim fields and prescriber identifiers
- Experience validating and reconciling data across multiple systems
- Strong knowledge of pharmacy fraud triggers and the regulatory framework governing pharmacy fraud, waste, and abuse
Complete Job Description
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