Pharmacy Payment Integrity Program Development Lead

Job Description

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 Payment Integrity Program Development Lead, 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.

Your Responsibilities and Impact will include:

• 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.

Required skills and experience:

• 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.

Desired skills and experience:

• 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

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Salary range: $105,000 - $155,000 annually

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

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....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family.  We are committed to a diverse and vibrant workforce. 

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.  And we've just started. So join us on this mission!

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.