Investigator, Special Investigations Unit

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🕒 Yesterday

⚜️ Louisiana, Montana, +3 more states – Remote

⚜️ Louisiana – Remote 🦬 Montana – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🎸 Mississippi – Remote

💵 $47k - $122.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

✨ Investigator

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Conducts investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, in order to recover lost funds, as well as to comply with state regulations mandating fraud plans and practices • Conducts investigations of known or suspected acts of healthcare fraud and abuse • Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases • Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc. • Facilitates the recovery of company and customer money lost as a result of fraud matters • Provides input regarding controls for monitoring fraud related issues within the business units • Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company • Maintains open communication with constituents internal and external to the company • Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse • Researches and prepares cases for clinical and legal review • Documents all appropriate case activity in tracking system • Makes referrals and deconflictions, both internal and external, in the required timeframe • Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations

🎯 Requirements

• 3+ years of experience working in fraud, waste and abuse investigations and audits • 3+ years of experience in healthcare/medical insurance claims investigation or professional/clinical experience • Demonstrated proficiency in Microsoft Office Suite (including Excel, specifically with pivot tables), database search tools, and use of the Intranet/Internet to research information • Strong analytical and research skills • Strong verbal and written communication skills • Strong customer service skills • Previous experience as a senior investigator • Previous experience utilizing QuickBase • Proficient in researching information and identifying information resources • Ability to utilize company systems to obtain relevant electronic documentation • Ability to travel and participate in legal proceedings, arbitrations, depositions, etc. • Ability to interact with different groups of people at different levels and aid on a timely basis • Previous experience working with a Third-Party Administrator (TPA) and/or Self-Funded Plans in an investigative capacity • AHFI (Accredited Health Care Fraud Investigator), CFE (Certified Fraud Examiner), and/or CPC (Certified Professional Coder) • Knowledge of CVS/Aetna/Meritain Health’s policies and procedures

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility