Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health

4d

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 Summary - 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.

Requirements

• 1+ years' experience working with Medicaid.
• 3+ years' in healthcare field working in fraud, waste and abuse investigations and audits.
• Proficient in researching information and identifying information resources.
• Experience working in Microsoft Word, Excel, Outlook products.
• Experience working with 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 New Jersey 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
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis.

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.

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
• Number of Employees: 5,001-10,000 employees