Analyst, Special Investigative Unit

CVS Health • Hartford, CT

314d • $43,888 - $93,574

About The Position

This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT). The role involves conducting investigations to effectively pursue the prevention, detection, investigation, and prosecution of healthcare fraud, waste, and abuse. Additionally, it requires reporting suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.

Requirements

• 1-3 years of Investigative experience in the area of healthcare fraud, waste and abuse
• Strong knowledge of medical terminology/CPT/HCPCS coding
• Advanced skills with Microsoft Excel
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience
• Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims
• Strong analytical and research skills
• Proficient in researching information and identifying information resources
• Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
• Strong verbal and written communication skills
• Strong customer service skills
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis
• Ability to utilize company systems to obtain relevant electronic documentation

Nice To Haves

• AHFI, CFE, Certified Professional Coder
• Knowledge of CVS/Aetna's policies and procedures

Responsibilities

• Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse
• Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
• Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others
• Facilitates the recovery of company and customer monetary losses
• Provides input regarding controls for preventing or monitoring fraud related issues within the business units
• Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
• Maintains open communication with constituents within and external to the company
• Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, and abuse
• Researches and prepares cases for clinical and legal review
• Documents all appropriate case activity in tracking system
• Makes referrals, both internal and external, in the required timeframe
• Exhibits behaviors outlined in Employee Competencies
• Exhibits behaviors outlined in SIU Investigator Competencies
• May include travel to testify in court proceedings or training if necessary

Benefits

• Full range of medical, dental, and vision benefits
• 401(k) retirement savings plan
• Employee Stock Purchase Plan
• Fully-paid term life insurance plan
• Short-term and long-term disability benefits
• Numerous well-being programs
• Education assistance
• Free development courses
• CVS store discount
• Discount programs with participating partners
• Paid Time Off (PTO) or vacation pay
• Paid holidays throughout the calendar year

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Bachelor's degree