Senior Investigator, Special Investigations Unit

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🔥 5 minutes ago

🌪️ Oklahoma – Remote

🌪️ Oklahoma – Remote

💵 $47k - $91.8k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Conduct high-level, complex investigations of suspected healthcare fraud and abuse • Investigate program-integrity matters involving aberrant Medicaid claims • Research subjects and related entities • Independently perform proactive data mining using SIU tools • Analyze claims data to identify aberrancy, patterns, and schemes • Prepare cases for clinical and legal review • Collaborate with Medical Directors on clinical issues and medical-record questions • Document case activity and communications in the designated tracking system • Communicate clinical findings to providers • Adhere to regulatory requirements • Facilitate recovery of company and customer funds lost through aberrant billing • Train and guide new and junior investigators • Assist junior investigators with resources and investigative strategies • Serve as backup to the Team Leader as needed • Collaborate with federal, state, and local law-enforcement agencies on healthcare-fraud investigations and prosecutions • Communicate fraud, waste, and abuse knowledge with internal and external stakeholders • Testify in civil and criminal proceedings • Develop professional presentations regarding healthcare fraud matters and the enterprise FWA approach • Recommend efficiency gains and provide input on FWA monitoring controls

🎯 Requirements

• Must reside in Oklahoma • 2–5 years investigative experience in healthcare fraud and abuse matters • Working knowledge of medical coding: CPT, HCPCS, ICD-10 • Proficient in Microsoft Office • Advanced Excel skills, including pivot tables • Power BI experience • Ability to initiate research vital to investigations • Proficient in researching information and identifying resources helpful to cases • Ability to travel up to 10% • Medicaid/Medicare investigation experience preferred • Knowledge of applicable Medicaid/Medicare rules and regulations preferred • Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI) credentials preferred • Knowledge and understanding of complex clinical issues preferred • Strong verbal and written communication skills • Strong analytical ability to analyze claims data from multiple perspectives • Bachelor's degree or equivalent experience (5+ years of working healthcare fraud, waste and abuse investigations)

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being

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