Senior Analyst, Investigations

CVS Health • Alabama, NY

32d

About The Position

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryThe Senior Analyst, Investigations at Aetna International plays a pivotal role in safeguarding the organization against fraud, waste, abuse (FWA), and compliance violations. This position is embedded within the International Special Investigations Unit (ISIU) and is designed to lead complex investigations into high-risk and sensitive matters that may compromise the integrity of the organization's operations and claims processes.Core ResponsibilitiesInvestigative Leadership: Conducts thorough investigations into suspected fraud, misconduct, or compliance breaches. These include analyzing billing and coding practices, verifying document authenticity, and identifying false claims or improper billing.Data-Driven Analysis: Utilizes advanced data analysis tools to detect patterns, anomalies, and trends that signal potential fraudulent activity. This includes mining claims data and leveraging forensic techniques to build evidence-based cases.Reporting & Documentation: Produces comprehensive investigative reports that summarize findings, outline evidence, and recommend actions such as disciplinary measures, restitution, or legal proceedings. These reports are shared with internal stakeholders and, when necessary, external regulatory bodies.Compliance Monitoring: Participates in audits and policy reviews to identify areas of non-compliance. Provides actionable recommendations to strengthen internal controls and mitigate riskCross-Functional Collaboration: Works closely with legal, compliance, internal audit, HR, and other departments to gather information, share findings, and support the investigative process. This collaboration ensures a holistic approach to risk management and resolution.Technology Integration: Advises on the selection and implementation of innovative technologies and forensic tools to enhance investigative efficiency and accuracy.Training & Awareness: Contributes to the development and delivery of training programs aimed at educating employees on fraud prevention, compliance obligations, and reporting mechanisms.Strategic ImpactThis role is critical to Aetna International's commitment to regulatory compliance and financial integrity. By proactively identifying and addressing FWA risks, the Sr Analyst helps protect the organization's reputation, ensures adherence to contractual and legal obligations, and supports global client commitments-especially in high-stakes international claims environments.

Requirements

• Prior Relevant Work Experience 3-5 years.
• Strong analytical and investigative skills, with experience in healthcare fraud detection.
• Proficiency in interpreting claims data, medical coding, and regulatory frameworks.
• Excellent communication and report-writing abilities.
• Collaborative mindset with the ability to work across departments and with external partners.

Nice To Haves

• Proficiency in Microsoft Outlook, Word, Excel, PowerPoint, and Teams.
• Ability to meet deadlines and make effective decisions.
• Strong time management and active listening skills.

Responsibilities

• Conducts thorough investigations into suspected fraud, misconduct, or compliance breaches. These include analyzing billing and coding practices, verifying document authenticity, and identifying false claims or improper billing.
• Utilizes advanced data analysis tools to detect patterns, anomalies, and trends that signal potential fraudulent activity. This includes mining claims data and leveraging forensic techniques to build evidence-based cases.
• Produces comprehensive investigative reports that summarize findings, outline evidence, and recommend actions such as disciplinary measures, restitution, or legal proceedings. These reports are shared with internal stakeholders and, when necessary, external regulatory bodies.
• Participates in audits and policy reviews to identify areas of non-compliance. Provides actionable recommendations to strengthen internal controls and mitigate risk
• Works closely with legal, compliance, internal audit, HR, and other departments to gather information, share findings, and support the investigative process. This collaboration ensures a holistic approach to risk management and resolution.
• Advises on the selection and implementation of innovative technologies and forensic tools to enhance investigative efficiency and accuracy.
• Contributes to the development and delivery of training programs aimed at educating employees on fraud prevention, compliance obligations, and reporting mechanisms.

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: Senior
• Industry: Ambulatory Health Care Services
• Number of Employees: 5,001-10,000 employees