Senior Investigator, Special Investigations Unit

Job not on LinkedIn

🔥 20 hours ago

🏈 Alabama, Arizona, +41 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $47k - $112.2k / 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 healthcare fraud and abuse • Handle high-profile or highly sensitive cases, including nationally scoped matters and complex multi-line, multi-subject, or intricate fraud schemes • Investigate program-integrity matters involving aberrant Medicaid claims • Research subjects and related entities • Independently perform proactive data mining with SIU tools to detect aberrant billing patterns and schemes • 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 to aberrant billing • Train and guide new and junior investigators • Assist junior investigators with resources and investigative strategy • Serve as Team Leader backup as needed • Collaborate with federal, state, and local law-enforcement agencies on healthcare-fraud investigations and prosecutions • Present healthcare fraud knowledge and findings to internal and external stakeholders • Testify in civil and criminal proceedings • Develop professional presentations about healthcare fraud and enterprise FWA approaches • Recommend efficiency gains and provide input on FWA monitoring controls

🎯 Requirements

• 3+ years investigative experience in healthcare fraud and abuse matters • Working knowledge of medical coding: CPT, HCPCS, ICD10 • Proficient in Microsoft Office • Advanced Excel skills; pivot tables required • Power BI experience • Strong analytical ability to analyze claims data from multiple facets • Ability to independently initiate vital investigative research • Proficient in researching information and identifying resources helpful to cases • Ability to travel up to 10% • Bachelor's degree or equivalent experience • Equivalent experience: 5+ years of working health care fraud, waste and abuse investigations • Preferred: 5+ years investigative experience in healthcare fraud and abuse matters • Preferred Medicaid/Medicare investigation experience and knowledge of applicable rules and regulations • Preferred CFE or AHFI credential • Knowledge and understanding of complex clinical issues preferred • Ability to exercise independent judgment and use resources and technology to develop evidence supporting fraud and abuse allegations • Strong verbal and written communication skills • Customer-focused ability to interact and collaborate with stakeholders and departments

🏖️ 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