Devoted Health · 3 weeks ago
Pharmacy Payment Integrity Program Development Lead
United States
Full-time
Remote
Senior Level
$105K/yr - $155K/yr
6+ years expDevoted Health is on a mission to improve the health and well-being of older Americans by providing integrated healthcare solutions. The Pharmacy Payment Integrity Program Development Lead will strategically oversee the FWA program, focusing on improving payment accuracy and mitigating fraud in the Medicare Advantage Prescription Drug line of business.
Elder CareElderlyHealth Care
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
Qualification
Required
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
Preferred
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
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
And more....
Company
Devoted Health
Devoted Health is a healthcare company serving seniors and giving them a health care plan with personal guides and world-class technology.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$2.26BKey Investors
Andreessen HorowitzVenrock
2024-08-02Series E· $112M
2023-12-29Series E· $175M
2021-10-08Series D· $1.15B
Leadership Team
Todd Park
Co-Founder, Executive Chairman
Adam Baratz
Technologist
Recent News
General Catalyst
2025-12-24
2025-12-03
Company data provided by crunchbase