Fraud, Waste & Abuse (FWA) Investigator – No Surprises Act (NSA)

CVS Health•Amherst, VT

4d•$66,330 - $145,860•Onsite

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 This individual contributor role supports complex investigations and contributes to organizational compliance with federal and state regulations. The position plays a key role in identifying fraud risks, supporting program integrity efforts, and helping to prevent financial losses related to fraud, waste, and abuse. Performs complex investigations related to healthcare fraud, waste, and abuse (FWA), with a focus on compliance with the No Surprises Act (NSA). This individual contributor role is responsible for analyzing healthcare data, conducting investigations, ensuring regulatory compliance, and supporting program integrity initiatives.

Requirements

5+ years of experience in healthcare fraud, waste, and abuse investigations or related program integrity functions
Experience analyzing healthcare claims data
Knowledge of healthcare regulatory requirements
Strong analytical, investigative, and problem-solving skills
Ability to manage multiple priorities and meet established timelines

Nice To Haves

Experience with the No Surprises Act (NSA)
Familiarity with CIDRE
Experience working with regulatory agencies or law enforcement
Certifications such as Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI)
Advanced knowledge of healthcare claims processing and billing practices

Responsibilities

Directs complex investigations, including data analysis, interviews, and document review, to identify potential fraud, waste, and abuse, including NSA-related activity.
Conducts investigations into suspected fraud, waste, and abuse associated with the No Surprises Act (NSA), including independent dispute resolutions.
Investigates dispute outcomes and identifies providers submitting non-NSA claims to CIDRE.
Prioritizes and manages cases to ensure timely, accurate, and compliant investigations.
Analyzes healthcare data and claims to identify patterns, trends, and anomalies indicative of fraud.
Supports risk mitigation efforts and ensures compliance with regulatory requirements, including NSA provisions.
Ensures investigative reports are accurate, complete, and compliant with legal and regulatory standards.
Develops and delivers training on fraud, waste, and abuse prevention, including NSA requirements.
Provides guidance and mentorship to team members during investigations.
Advises management on fraud trends, regulatory changes, and best practices.
Collaborates with internal partners and external stakeholders to support investigations.
Partners with law enforcement, as appropriate, to support investigation and prosecution efforts.
Maintains stakeholder communication and provides input on fraud risk controls.