Lead Director, Special Investigation - Medicaid

CVS Health • Hartford, CT

20h • Hybrid

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: Reporting to the SIU Executive Director, the Lead Director of Medicaid is responsible for oversight of the Special Investigations Unit detection, investigation, and prevention of Fraud, Waste and abuse schemes impacting Aetna's Medicaid line of business. The director will have oversight of a team of Managers, Sr. Investigators and investigators, and other colleagues, responsible for conducting confidential and sensitive investigations for the purpose of detecting, reporting upon, and remediating fraud, waste, and abuse in the Medicaid line of business. Activities Include: Oversees the Medicaid Special Investigations Unit, including Managers and investigators. Establishes SIU policies, procedures, and practices, making recommendations for improvements where needed. Provides guidance to and ensures training for Managers and investigators regarding obtaining evidence, sufficiency of evidence, investigative interviews, and other investigatory techniques and practices. Coordinates with state and federal law enforcement regarding matters under investigation Identifies potential investigative issues, subjects, and targets. Leads staff in developing, reviewing, and editing investigative plans and proposals. Oversees the drafting and issuance of public reports, making recommendations to state agencies involved in Medicaid Provides guidance on investigative and litigation strategies and issues; troubleshoots with staf to identify solutions. Develops expertise in applicable laws, rules, regulations, and other standards related to the work of OSC and MFD; advises on the application of federal and state law. Communicates with various external stakeholders, including representatives from state and federal government and the healthcare industry. As part of a team, engages in a thorough and rigorous quality control process to ensure the accuracy and objectivity of investigative findings.

Requirements

• 10 years of experience as a Senior investigator with at least three years of Senior Investigations Manager experience or equivalent experience in FWA Compliance or Internal Audit.
• Minimum of 5 years of experience working with a Medicaid healthcare agency, managed care organization, or law enforcing agency.
• Experience with litigation and criminal or civil investigations in a supervisory capacity.
• Excellent writing skills with an ability to draft, edit, and finalize investigative findings and reports.
• Excellent public speaking skills.
• Demonstrated competency in workforce modelling and management including colleague productivity and quality monitors
• Bachelors or Master’s degree or equivalent experience required

Responsibilities

• Oversees the Medicaid Special Investigations Unit, including Managers and investigators.
• Establishes SIU policies, procedures, and practices, making recommendations for improvements where needed.
• Provides guidance to and ensures training for Managers and investigators regarding obtaining evidence, sufficiency of evidence, investigative interviews, and other investigatory techniques and practices.
• Coordinates with state and federal law enforcement regarding matters under investigation
• Identifies potential investigative issues, subjects, and targets.
• Leads staff in developing, reviewing, and editing investigative plans and proposals.
• Oversees the drafting and issuance of public reports, making recommendations to state agencies involved in Medicaid
• Provides guidance on investigative and litigation strategies and issues; troubleshoots with staf to identify solutions.
• Develops expertise in applicable laws, rules, regulations, and other standards related to the work of OSC and MFD; advises on the application of federal and state law.
• Communicates with various external stakeholders, including representatives from state and federal government and the healthcare industry.
• As part of a team, engages in a thorough and rigorous quality control process to ensure the accuracy and objectivity of investigative findings.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager