Senior Investigator, Special Investigation Unit (Fully Remote)

CVS Health

1d•Remote

About The Position

This position conducts 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. The role involves investigating known or suspected acts of healthcare fraud and abuse, communicating with federal, state, and local law enforcement agencies, and preventing payment of fraudulent claims. Key responsibilities include facilitating the recovery of company and customer money lost due to fraud, providing input on fraud monitoring controls, and delivering educational programs to deter fraud. The investigator maintains open communication with internal and external constituents, utilizes resources and technology for evidence development, researches and prepares cases for clinical and legal review, and documents all case activity. They are also responsible for making referrals and deconflictions in a timely manner, cost-effectively managing outside resources, and attending and presenting at quarterly state meetings.

Requirements

1+ years' experience working with Medicaid.
Over 3 years in healthcare field working in fraud, waste and abuse investigations and audits.
Proficient in researching information and identifying information resources.
Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
Experience working in Microsoft Word, Excel, Outlook products.
Database search tools, and use in the Intranet/Internet to research information.
Ability to utilize company systems to obtain relevant electronic documentation.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice To Haves

Knowledge of Virginia Medicaid.
Credentials such as a certification from the Association of Certified Fraud Examiners (CFE).
An accreditation from the National Health Care Anti-Fraud Association (AHFI).
Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
Knowledge of Aetna's policies and procedures.

Responsibilities

Conducts 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.
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 within 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.
Exhibits behaviors outlined in Employee Competencies.
Attending and presenting at quarterly state meetings.