Senior Investigator, Special Investigations Unit

Job not on LinkedIn

🔥 6 minutes ago

🏈 Alabama, Arizona, +41 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – 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 - $102k / 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 to prevent payment of fraudulent claims submitted to Medicaid lines of business • Research and prepare cases for clinical and legal review • Document 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 company and customer money lost through fraud matters • Provide on-the-job training and guidance to less experienced Investigators • Assist Investigators with resources and best courses of action • Serve as backup to the Team Leader as necessary • Cooperate with federal, state, and local law enforcement in healthcare fraud investigations and prosecutions • Provide testimony during civil and criminal proceedings • Present to internal and external customers on healthcare fraud matters and Aetna's approach • Provide input on fraud-monitoring controls within business units

🎯 Requirements

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

🏖️ 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