Senior Investigator, Special Investigations Unit

Job not on LinkedIn

🔥 3 minutes ago

🌪️ Oklahoma – Remote

🌪️ Oklahoma – Remote

💵 $47k - $91.8k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

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 healthcare fraud and abuse • Investigate program-integrity matters to prevent payment of aberrant Medicaid claims • Conduct thorough research on subjects and related entities • Independently initiate proactive data mining using SIU tools to identify aberrant billing patterns and detect schemes early • Analyze claims data to determine aberrancy, patterns, or schemes • Research and 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 case-tracking system • Communicate clinical findings to providers • Adhere to regulatory requirements • Facilitate case outcomes to recover company and customer monies lost from aberrant billing • Provide training and guidance to new and junior investigators • Assist junior investigators with resources and investigative strategy • Serve as backup to the Team Leader as necessary • Collaborate with federal, state, and local law-enforcement agencies on healthcare-fraud investigations and prosecutions • Testify in civil and criminal proceedings • Prepare and deliver presentations on healthcare-fraud matters and the enterprise FWA approach • Communicate efficiency-gain ideas 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, ICD10 • Proficient in Microsoft Office • Advanced skills in Excel; pivot tables are a must • Power BI skills • Self-starter who initiates research vital to an investigation • Proficient in researching information and identifying new 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 • Ability to effectively interact and collaborate with various stakeholders and departments preferred • Strong verbal and written communication skills preferred • Strong analytical ability to view and slice claims data in multiple facets preferred • Bachelor's degree or equivalent experience (5+ years of working health care 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