Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health

3d•$46,988 - $112,200•Onsite

About The Position

Conducts high level, complex analysis of Pharmacy and Prescriber behavior to effectively pursue the prevention, investigation and prosecution of Fraud Waste and Abuse. Collaboration with Pharmacy Benefit Manager, providing meaningful evidence of Fraud, Waste and Abuse to support Pharmacy Audit activities. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving Pharmacies and Prescribers. Investigates to prevent payment of fraudulent activities committed by Pharmacies and Prescribers. Researches and prepares cases for clinical, legal and leadership review. Documents all appropriate case activity in case tracking system. Makes referrals, both internal and external, in the required timeframe. Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution. 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 Pharmacy Fraud matters. Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units. Maintains open communication with constituents within and external to the company.

Requirements

3-5 years investigative experience in the area of Healthcare and Pharmacy fraud, waste and abuse.
Knowledge of Pharmacy and Medical terminology.
Experience with Microsoft Office products, specifically Microsoft Excel, and Database search tools.
Proficient in data analysis and research.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice To Haves

Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Bilingual in English/Spanish
Strong verbal and written communication skills.
Strong customer service skills.
Knowledge of CVS/Aetna's policies and procedures
Ability to interact with different groups of people at different levels.
Ability to utilize company systems to obtain relevant electronic documentation.

Responsibilities

Conducts high level, complex analysis of Pharmacy and Prescriber behavior to effectively pursue the prevention, investigation and prosecution of Fraud Waste and Abuse.
Collaborates with Pharmacy Benefit Manager, providing meaningful evidence of Fraud, Waste and Abuse to support Pharmacy Audit activities.
Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving Pharmacies and Prescribers.
Investigates to prevent payment of fraudulent activities committed by Pharmacies and Prescribers.
Researches and prepares cases for clinical, legal and leadership review.
Documents all appropriate case activity in case tracking system.
Makes referrals, both internal and external, in the required timeframe.
Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution.
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 Pharmacy Fraud matters.
Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units.
Maintains open communication with constituents within and external to the company.