Senior Investigator-Special Investigations Unit (SIU) (Must reside in Ohio)

CVS Health

About The Position

As a Senior Investigator, you will conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse. This role routinely handles sensitive, high-profile, national, or complex cases involving multiple perpetrators or intricate healthcare fraud schemes. The primary objective is to prevent the payment of fraudulent claims submitted to Medicaid lines of business. Responsibilities include researching and preparing cases for clinical and legal review, documenting all case activity, facilitating feedback with providers on clinical findings, and initiating proactive data mining to identify aberrant billing patterns. You will also be responsible for making internal and external referrals within required timeframes and facilitating the recovery of money lost due to fraud. Additionally, the Senior Investigator provides on-the-job training and guidance to new and less experienced Investigators, assists them in identifying resources and best courses of action, and serves as a backup to the manager when necessary. The role requires cooperation with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. You will be expected to demonstrate a high level of knowledge and expertise during interactions, act confidently when providing testimony in civil and criminal proceedings, and give presentations to internal and external customers regarding healthcare fraud and Aetna's approach to fighting fraud. Finally, you will provide input regarding controls for monitoring fraud-related issues within the business unit.

Requirements

Must live in the state of Ohio
4+ years investigative experience in the area of healthcare fraud, waste and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
The ability to understand and analyze health care claims and coding
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Bachelor's degree or equivalent experience (A bachelor's degree, or an associate's degree with an additional four+ years working on health care fraud, waste, and abuse investigations and audits)

Nice To Haves

Previous Medicaid/Medicare investigatory experience
Previous Behavioral Health experience
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of Aetna's policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation

Responsibilities

Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases, or cases involving multiple perpetrators or intricate healthcare fraud schemes
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
Makes referrals, both internal and external, in the required timeframe
Facilitates the recovery of money lost as a result of fraud matters
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the manager as necessary
Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
Provides input regarding controls for monitoring fraud related issues within the business unit