Senior Investigator, Special Investigations Unit – SIU

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🔥 4 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $47k - $102k / 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 known or suspected healthcare fraud and abuse • Investigate to prevent payment of fraudulent claims submitted to Medicaid lines of business • Research and prepare cases for clinical and legal review • Document appropriate case activity in the case tracking system • Facilitate feedback with providers regarding clinical findings • Initiate proactive data mining to identify aberrant billing patterns • Make internal and external referrals within required timeframes • Facilitate recovery of money lost through fraud matters • Provide on-the-job training and guidance to less experienced Investigators • Assist Investigators in identifying resources and the best course of action • Serve as backup to the manager as necessary • Cooperate with federal, state, and local law enforcement in healthcare fraud investigations and prosecutions • Provide expert testimony during civil and criminal proceedings • Present healthcare fraud matters and Aetna's approach to internal and external customers • Provide input on controls for monitoring fraud-related issues within the business unit

🎯 Requirements

• 4+ years investigative experience in healthcare fraud, waste and abuse matters • Working knowledge of medical coding: CPT, HCPCS, ICD10 • Proficiency in Microsoft Office • Advanced Excel skills, including pivot tables • Ability to understand and analyze health care claims and coding • Ability to travel up to 10% (approximately 2–3 times per year, depending on business needs) • Bachelor's degree or equivalent experience • Alternatively, an associate's degree with an additional 4+ years working on health care fraud, waste, and abuse investigations and audits • Ohio residency preferred • Previous Medicaid/Medicare investigatory experience preferred • Previous Behavioral Health experience preferred • CFE or AHFI credentials preferred • Knowledge of Aetna's policies and procedures preferred • Knowledge and understanding of complex clinical issues preferred • Competence with legal theories preferred • Strong communication and customer service skills • Ability to effectively interact with different groups of people at different levels • Strong analytical and research skills • Proficiency in researching information and identifying information resources • Strong verbal and written communication skills

🏖️ Benefits

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

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