Senior Investigator, Special Investigations Unit – SIU

Job not on LinkedIn

🔥 14 hours 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 suspected healthcare fraud and abuse • Investigate program-integrity matters involving aberrant Medicaid claims • Research subjects and related entities • Independently conduct proactive data mining using SIU tools • Analyze claims data to identify aberrancy, patterns, and 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 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 strategy • Serve as backup to the Team Leader as needed • Collaborate with federal, state, and local law-enforcement agencies on healthcare-fraud investigations and prosecutions • Present healthcare-fraud findings and FWA knowledge to internal and external stakeholders • Testify in civil and criminal proceedings • Develop professional presentations on healthcare fraud matters and enterprise FWA approaches • 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, including CPT, HCPCS, and ICD10 • Proficient in Microsoft Office • Advanced Excel skills, including pivot tables • Power BI skills • Self-starter who initiates research vital to investigations • Proficient in researching information and identifying new case resources • 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 health care fraud, waste and abuse investigations)

🏖️ 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 in addition to base pay