Senior Healthcare Fraud Investigator (Aetna SIU)
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About The Position
As a Senior Investigator at CVS Health, you will conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse. This role involves handling sensitive or high-profile cases that may be national in scope, complex cases involving multiple lines of business, or cases with multiple perpetrators or intricate healthcare fraud schemes. Your responsibilities will include investigating to prevent payment of fraudulent claims submitted to the Medicaid lines of business, researching and preparing cases for clinical and legal review, documenting all appropriate case activity in the case tracking system, and facilitating feedback with providers related to clinical findings. You will also initiate proactive data mining to identify aberrant billing patterns, make referrals in the required timeframe, and facilitate the recovery of company and customer money lost due to fraud. Additionally, you will provide on-the-job training to new investigators, assist in identifying resources for investigations, and cooperate with law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. You will demonstrate a high level of knowledge and expertise during interactions and act confidently when providing testimony during civil and criminal proceedings. Furthermore, you will give presentations regarding healthcare fraud matters and provide input on controls for monitoring fraud-related issues within the business units.
