Senior SIU Investigator

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🔥 13 minutes ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $47k - $91.8k / 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 • Handle high profile or highly sensitive matters involving cases that are national in scope • Investigate matters of program integrity to prevent payment of aberrant claims • Conduct thorough research on subject(s) and related entities • Initiate proactively data mining using SIU Tools to identify aberrant billing patterns • Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme • Research and prepare cases for clinical and legal review • Accurately document all case activity and communications in designated case tracking system • Communicate clinical findings to provider • Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing

🎯 Requirements

• Must reside in Louisiana • 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 (pivot tables are a must, Power BI, etc.) • 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%

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package designed to support physical, emotional, and financial well-being