Pharmacy Fraud Program Manager

We need to output only HTML fragment, with headings

for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Use

• for any list of duties/requirements/benefits, and

  for prose. Do NOT repeat job title as heading. Do NOT put Job ID/requisition numbers as headings. Preserve all substantive info; remove boilerplate, navigation, legal, EEO, etc. Include a section only when posting has real specific content. Avoid filler like "commensurate with experience". Pay and Schedule sections only if posting actually states them. The posting includes Salary range: $73,000 - $130,000 / year. So we can have Pay section with that. Schedule? Not mentioned (full-time on-site). It says Full-time On-site Waltham Massachusetts Office. That's schedule info: full-time, on-site. Could include Schedule section with "Full-time, on-site in Waltham, MA". That's specific. Benefits: The posting includes "Our Total Rewards Package Includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more....". So we can include Benefits section with those bullet points. We also have sections: About the role (the initial paragraph describing role). Responsibilities (the list under "Your Responsibilities And Impact Will Include:" with sub-sections like CFWA Relationship Management, Data Validation & Source Reconciliation, AI-Assisted Detection & Validation, Pharmacy Fraud Detection, Triggers & Red Flags, Case Referrals, Collaboration & Mentorship). Requirements (maybe "Required Skills And Experience:" list). Qualifications? Might be overlapping with Required Skills. Could treat "Required Skills And Experience:" as Requirements. Desired Skills And Experience could be Skills? Or we could have Skills section for desired? But we need to avoid thin sections. We can combine Required and Desired into Skills? But better to follow headings: Requirements (required), Skills (desired). Qualifications maybe not needed if covered. But we can include Qualifications as education requirement? The required includes Bachelor's degree etc. Could put that in Qualifications. However we need to avoid duplication. Let's structure:

  About the role

  ... (the paragraph starting "A bit about this role:" up to before "Your Responsibilities And Impact Will Include:"). Then

  Responsibilities

  with each responsibility as
  • . Might need to keep sub-bullets? The responsibilities have headings like CFWA Relationship Management — CVS etc. We can treat each heading as a
  • with its description inside maybe as

    inside

  • ? But spec says use
    • for any list of duties/requirements/benefits. So each duty can be a
    • . Inside
    • we can have multiple sentences. That's fine. Then

      Requirements

      for Required Skills And Experience items. Then

      Skills

      for Desired Skills And Experience items. Then

      Benefits

      for benefits list. Then

      Pay

      Salary range: $73,000 - $130,000 per year.

      Then

      Schedule

      Full-time, on-site in Waltham, MA.

      We must ensure we don't include filler like "commensurate with experience". Not present. We must remove boilerplate: EEO, equal opportunity, legal, etc. Also remove duplicated lines, navigation, cookie, application instructions, etc. Also remove the "job#onApply" etc. Also remove the repeated responsibilities block that appears later (the duplicate after "Your Responsibilities And Impact Will Include: CFWA Relationship Management — CVS ..." appears again later near the end? Actually after the benefits there is a duplicate of responsibilities? The text shows after benefits there is "Your Responsibilities And Impact Will Include: CFWA Relationship Management — CVS Serve as the primary point of contact..." again. That's duplicate; we should only include once. We need to preserve all substantive info; not invent. Let's extract the About the role paragraph: "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." That is the About. Now Responsibilities list: Under "Your Responsibilities And Impact Will Include:" we have several sections: - 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 are accurate, complete, and defensible. Trace data lineage across internal systems and PBM-supplied files, corroborating information against authoritative sources to confirm or refute investigative hypotheses. - AI-Assisted Detection & Validation Use AI- and machine learning–driven detection tools to flag suspicious patterns, score risk, and surface high-priority cases for review. Validate AI-generated alerts and model outputs against source claims and clinical data, distinguishing genuine fraud indicators from false positives, data artifacts, and legitimate clinical variation. Provide structured feedback to analytics, vendor, and PBM partners to improve model accuracy, tuning, and rule logic over time. Stay current on emerging AI-enabled fraud schemes (e.g., synthetic identities, deepfakes, generated prescriptions or prior authorization documentation, fraudulent e-prescribing credentials) and adapt detection approaches accordingly. - Pharmacy Fraud Detection, Triggers & Red Flags Apply deep knowledge of pharmacy fraud triggers, red flags, and typologies — including prescribing and dispensing patterns — to proactively identify suspicious activity before it escalates. Develop, refine, and document indicators and detection criteria based on emerging schemes and investigative learnings. Investigate referrals and self-sourced leads, building complete case referrals supported by validated evidence. - Case Referrals Conduct thorough data validation into suspected fraudulent activity, documenting methodology, findings, and conclusions. Maintain accurate, audit-ready case records in the case management system. Prepare clear written summaries and present findings to leadership, business partners, legal, and, when appropriate, law enforcement or regulatory bodies. - Collaboration & Mentorship Partner with claims, payment integrity, underwriting, compliance, legal, and data teams — as well as pharmacy operations and clinical and pharmacy services — to share intelligence and strengthen controls. Work and collaborate with the Fraud Program Manager on overall fraud detection and scheme identification. Mentor junior analysts on data validation techniques, investigative methodology, and red-flag recognition. Contribute to continuous improvement of SIU processes, tools, and detection capabilities. We'll make each bullet a
      • . Now Required Skills And Experience list: - Bachelor's degree in Criminal Justice, Finance, Data Analytics, Health Administration, Pharmacy, Business, or a related field — or equivalent investigative experience. - 5+ years of experience in fraud investigation, financial crime, pharmacy benefit or claims analysis, or a closely related field, ideally within an SIU or comparable environment. - Demonstrated experience with pharmacy claims data and pharmacy benefit operations, including familiarity with NCPDP claim fields, NDCs, formulary and prior authorization concepts, and prescriber/pharmacy identifiers (NPI, DEA, state license). - Demonstrated experience validating and reconciling data across multiple, disparate systems and sources. - Experience managing or supporting a vendor, PBM, or delegated-entity relationship, including referral coordination, reporting review, and performance follow-up. - Strong working knowledge of pharmacy fraud triggers, red flags, and common fraud schemes, and of the regulatory framework governing pharmacy FWA. - Hands-on experience using analytical, detection, or case management tools, including AI/ML-assisted detection platforms. - Excellent analytical, critical-thinking, and problem-solving skills, with a naturally inquisitive and skeptical approach. - Strong written and verbal communication skills, with the ability to present complex findings clearly and concisely. Now Desired Skills And Experience list: - Professional certification such as CFE (Certified Fraud Examiner), CFCS, AFE, AHFI, CPhT, or equivalent. - Direct experience with CVS/Caremark data, reporting, or FWA processes. - Experience with controlled substance monitoring, opioid overutilization programs, or PDMP data. - Experience working with data visualization tools, or analytical querying of large data sets. Now Benefits list: - Employer sponsored health, dental and vision plan with low or no premium - Generous paid time off - $100 monthly mobile or internet stipend - Stock options for all employees - Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles - Parental leave program - 401K program - And more.... (maybe we can keep "And more...." but it's vague; maybe we can omit as filler? It's not specific. Better to omit "And more...." as it's not substantive. We'll keep the specific items. Now