Senior Investigator, Special Investigations Unit

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🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $47k - $102k / year

⏰ Full Time

🟠 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

• Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment • Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc. • Researches and prepares cases for clinical and legal review. • Documents all appropriate case activity in case tracking system. • Prepares and presents referrals, both internal and external, in the required timeframe. • Facilitates the recovery of company lost as a result of fraud matters. • Assists team in identifying resources and best course of action on investigations. • Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. • Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings. • Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud. • Provides input regarding controls for monitoring fraud related issues within the business units. • Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse

🎯 Requirements

• Must reside in Florida. • 3 years working on health care fraud, waste, and abuse investigatory and audits required. • Knowledge of CPT/HCPCS/ICD coding • Knowledge and understanding of clinical issues. • Experience and proficiency in Microsoft Word, Excel, and Outlook, Database search tools, and use in the Intranet/Internet to research information. • Ability to travel and participate in legal proceedings, arbitrations, depositions, etc. • Ability to travel to provider offices within the state of Florida on a monthly basis

🏖️ Benefits

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