Behavioral Health Senior Investigator (BCBA), Special Investigations Unit (Aetna SIU)

CVS Health•Hartford, CT

3d•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Behavioral Health Senior Investigator is responsible for conducting complex investigations involving Applied Behavior Analysis (ABA) services and behavioral health providers to identify, detect, and prevent potential fraud, waste, and abuse (FWA). This position utilizes clinical and investigative knowledge to analyze provider billing patterns, service utilization, treatment documentation, and regulatory compliance to identify aberrant activity and support investigative outcomes.

Requirements

Current Board-Certified Behavior Analyst (BCBA) certification.
Minimum 2-3 years of experience providing ABA services.
Experience conducting behavioral assessments and treatment planning.
Ability to Travel for Business purposes.

Nice To Haves

Experience working with Autism Spectrum Disorder (ASD) populations.
Knowledge of healthcare, managed care, or behavioral health systems.
Experience in interdisciplinary care coordination.
Experience supporting healthcare fraud, waste, and abuse (FWA) investigations.
Knowledge of healthcare claims, coding, reimbursement methodologies, and payer audit processes.
Experience conducting provider record reviews, utilization analysis, or compliance audits.
Familiarity with Medicaid, Medicare, commercial health plan operations, and behavioral health reimbursement practices.
Strong analytical, communication, and organizational skills.

Responsibilities

Conduct behavioral health and ABA-retrospective reviews to identify potential fraud, waste, abuse, and quality of care concerns.
Analyze clinical documentation, treatment plans, progress notes, billing records, and utilization patterns for indicators of inappropriate services, overutilization, unbundling, duplicate billing, or services not supported by clinical documentation.
Partner with Special Investigations Unit (SIU), Compliance, Legal, Network, and Medical Management teams to support investigations involving ABA providers, behavioral health practitioners, and related service providers.
Perform clinical reviews and provide subject matter expertise regarding ABA standards of care, medical necessity, and treatment appropriateness.
Identify emerging fraud schemes, billing anomalies, and provider outlier trends through data analysis and case review activities.
Prepare concise investigative summaries, clinical findings, and recommendations for internal stakeholders and leadership.
Participate in provider audits, site visits, record reviews, and corrective action initiatives as needed.
Support recovery, prepayment review, and provider education efforts when inappropriate billing or service delivery concerns are identified.
Ensure investigations and reviews comply with applicable regulatory requirements, payer policies, BACB ethical standards, state regulations, and organizational compliance expectations.
Contribute to the development of fraud prevention strategies, provider education materials, and investigative business rules designed to detect and mitigate fraud, waste, and abuse.