Pharmacy Program Integrity Development Lead

Devoted Health

16d • Remote

About The Position

A bit about this role: At Devoted, we know that one of the most important ways we build trust with our network and members is to pay claims accurately and on time while having transparent payment policies. Our Program Integrity Department ensures that claims are paid correctly by the responsible party, for eligible members, according to contractual terms, not in error or duplicate, and free of fraudulent, wasteful or abusive practices. As the Pharmacy Program Integrity Development Senior Manager, you will serve as the principal strategic owner and hands-on driver of our FWA program within the Medicare Advantage Prescription Drug (MAPD) line of business (Part B and D). You will be responsible for identifying and researching new cost containment and compliance opportunities to improve payment accuracy and mitigate prescription drug fraud, waste, abuse . You will assess new opportunities by leveraging your deep Medicare Part B/ D regulatory expertise, researching and evaluating CMS FWA policies and industry trends, analyzing internal medical and prescription drug claims data, and leading critical cross-functional collaboration.

Requirements

• Bachelor's degree and a minimum of 6+ years of progressive experience in Pharmacy Benefit Management (PBM), Managed Care, or Health Plan FWA/Payment Integrity, with a primary focus on the Medicare Part B/D prescription drug regulatory environment.
• Expert-level knowledge of Medicare Part B/D claims processing and CMS FWA requirements (42 CFR 423 Subpart K).
• Strong communications skills (verbal, written, presentation, interpersonal) with all types/levels of audience, including the ability to articulate complex FWA findings to executives.
• Ability to multitask, effectively prioritize critical tasks, and drive outcomes across cross-functional teams without direct reporting authority.
• Ability to understand, explain, and break down complex problems related to regulatory compliance and pharmacy claims processing.

Nice To Haves

• Clinical credentials (e.g., Pharmacist, CPhT).
• Experience working with or overseeing PBM program integrity vendors, analytics platforms, or investigative case pipelines; experience with RxShield is a plus.
• Prior involvement in CMS audits, ODAG/DAG reviews, MEDIC referrals, or PBM compliance monitoring.
• Expert proficiency in querying large datasets using SQL

Responsibilities

• Lead the design and execution of the multi-year strategic roadmap for the Pharmacy FWA program, including vendor utilization, tool enhancements, and scheme prioritization.
• Proactively and independently analyze integrated medical and pharmacy data (e.g., medical claims, PDEs, POS pharmacy claims, prior authorizations) to detect patterns of abnormal utilization, high-risk prescriber/pharmacy indicators, and emerging prescription drug fraud schemes.
• Leverage your deep subject matter expertise, policy research, industry trends, and internal data to generate and prove out novel FWA theories and program concepts that reduce inappropriate prescription drug utilization and claims activity.
• Partner with and provide insights and recommended actions to internal teams (e.g., Compliance, Special Investigations Unit (SIU), Clinical, Networks) and the PBM Program Integrity team to address identified claims payment inaccuracies, quantify financial impact, and ensure timely submission of high-quality case leads to the SIU..
• Independently create and iterate data sets using advanced query tools to research ideas and develop data insights.
• Govern the rulesets and algorithms within the third-party FWA analytics platform to maximize high-yield case detection.
• Prepare and present regular reports to Executive Leadership on program ROI, regulatory risk exposure, net recoveries, and the strategic direction of the Pharmacy FWA program.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees