Senior Investigator, Special Investigations Unit

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🔥 12 minutes ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $47k - $112.2k / year

⏰ Full Time

🟠 Senior

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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

• Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse • Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment • Conduct thorough research on subject(s) and related entities • Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection • Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme • Research and prepare cases for both clinical and legal review • Collaborate with Medical Directors on clinical issues and medical record questions • Accurately documents all case activity and communications in designated case tracking system • Communicate clinical findings to provider • Adherent to all regulatory requirements • Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing • Provide training and guidance to new and junior investigators • Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy • Serve as back up to the Team Leader as necessary • Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues • Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings • Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders

🎯 Requirements

• 5+ years investigative experience in healthcare fraud and abuse matters • Working knowledge of medical coding; CPT, HCPCS, ICD10 • Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables. • Strong analytical ability to view and slice claims data in multiple facets • Self-starter: initiates research that will be vital to an investigation • Proficient in researching information and identifying new resources helpful to all cases • Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.) • Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

🏖️ Benefits

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