Investigator, Special Investigations Unit (Aetna SIU) - Must reside in Oklahoma

CVS Health•Work At Home-Oklahoma, OK

1d•$43,888 - $76,500•Remote

About The Position

The Special Investigations Unit (SIU) Investigator is responsible for thoroughly investigating any allegations of Medicaid healthcare fraud, waste, or abuse in accordance with federal and state regulation. This position will be responsible for collaborating with Compliance, State Medicaid Plans, Health Plans, and Coding teams. Oklahoma residence required. Review concern/allegation, develop an investigation plan, identify additional information needed, and individuals to interview. Manage an active caseload ensuring timely and thorough task completions while adhering to legal and organizational standards. Interview healthcare providers, patients/members, and others to gather information pertinent to the investigation. Use data analytics and software tools to analyze billing patterns, identify anomalies, and detect suspicious activities. Use medical records, billing data, and coding systems to ensure compliance with regulations and code requirements. Partner with the Senior Investigator, as needed, to support FWA case activities and ensure alignment on investigative strategy and next steps. Partner with the Clinical team to support pre-payment and post-payment coding reviews. Collaborate with SIU Compliance and PI Managers for specific state requirements and deliverables. Refer cases to law enforcement and regulatory agencies as required by state plans. Coordinate with internal legal teams to review findings, case outcomes, prepare evidence for potential court cases or administrative hearings. Prepare comprehensive investigation reports that document fact findings and provide recommendations for appropriate corrective action outcomes. Maintain and document accurate records of all investigations, including evidence collected, interviews, and outcomes. Monitor and promote healthcare provider adherence to applicable federal and state requirements, as well as payer billing and claims guidelines. Communicate case outcomes to healthcare providers and complete follow-up outreach as needed.

Requirements

Must reside in Oklahoma.
Experience in working healthcare investigations.
2 years of experience in healthcare fraud investigation.
Experience with using fraud, waste, and abuse (FWA) detection tools and enterprise databases to support data mining, analysis, and information gathering.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice To Haves

Credential(s) such as Certified Fraud Examiners (CFE) and National Health Care Anti-Fraud Association (AHFI).
3+ years Medicaid Fraud, Waste and Abuse investigatory experience.
Coding certification such as CPC (AAPC) and/or CCS (AHIMA).
Knowledge of Behavioral Health care delivery, policies and procedures, and contractual implications.
Knowledge of healthcare laws, regulations, and CPT/HCPCS coding.
Strong analytical and investigative skills.
Strong communication skills needed for interviewing and presentations to Health Plans and State Regulators.
Strong documentation/writing skills needed for presentations and case documentation.

Responsibilities

Review concern/allegation, develop an investigation plan, identify additional information needed, and individuals to interview.
Manage an active caseload ensuring timely and thorough task completions while adhering to legal and organizational standards.
Interview healthcare providers, patients/members, and others to gather information pertinent to the investigation.
Use data analytics and software tools to analyze billing patterns, identify anomalies, and detect suspicious activities.
Use medical records, billing data, and coding systems to ensure compliance with regulations and code requirements.
Partner with the Senior Investigator, as needed, to support FWA case activities and ensure alignment on investigative strategy and next steps.
Partner with the Clinical team to support pre-payment and post-payment coding reviews.
Collaborate with SIU Compliance and PI Managers for specific state requirements and deliverables.
Refer cases to law enforcement and regulatory agencies as required by state plans.
Coordinate with internal legal teams to review findings, case outcomes, prepare evidence for potential court cases or administrative hearings.
Prepare comprehensive investigation reports that document fact findings and provide recommendations for appropriate corrective action outcomes.
Maintain and document accurate records of all investigations, including evidence collected, interviews, and outcomes.
Monitor and promote healthcare provider adherence to applicable federal and state requirements, as well as payer billing and claims guidelines.
Communicate case outcomes to healthcare providers and complete follow-up outreach as needed.