Investigator, Special Investigations Unit (Meritain Health)

CVS Health•New York, MS

1d•$46,988 - $122,400•Remote

About The Position

As an independently owned subsidiary of Aetna and CVS Health, Meritain Health is a leading third-party administrator of self-insured commercial health plans. The SIU Investigator will support Meritain Health’s Network Cost Management team, specifically the Special Investigations Unit (SIU). The SIU Investigator will conduct investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.

Requirements

3+ years of experience working in fraud, waste and abuse investigations and audits.
3+ years of experience in healthcare/medical insurance claims investigation or professional/clinical experience.
Demonstrated proficiency in Microsoft Office Suite (including Excel, specifically with pivot tables), database search tools, and use of the Intranet/Internet to research information.

Nice To Haves

Strong analytical and research skills.
Strong verbal and written communication skills.
Strong customer service skills.
Previous experience as a senior investigator.
Previous experience utilizing QuickBase.
Proficient in researching information and identifying information resources.
Ability to utilize company systems to obtain relevant electronic documentation.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Ability to interact with different groups of people at different levels and aid on a timely basis.
Previous experience working with a Third-Party Administrator (TPA) and/or Self-Funded Plans in an investigative capacity.
AHFI (Accredited Health Care Fraud Investigator), CFE (Certified Fraud Examiner), and/or CPC (Certified Professional Coder).
Knowledge of CVS/Aetna/Meritain Health’s policies and procedures

Responsibilities

Conducts investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, in order to recover lost funds, as well as to comply with state regulations mandating fraud plans and practices.
Conducts investigations of known or suspected acts of healthcare fraud 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 claims committed by insured's, providers, claimants, customer members, etc.
Facilitates the recovery of company and customer money lost as a result of fraud matters.
Provides input regarding controls for 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 internal and external to the company.
Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Researches and prepares cases for clinical and legal review.
Documents all appropriate case activity in tracking system.
Makes referrals and deconflictions, both internal and external, in the required timeframe.
Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.