Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health

22h•$46,988 - $112,200•Remote

About The Position

As a Senior Investigator, you will conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse. You will routinely handle cases that are sensitive or high-profile, complex cases involving multiple perpetrators or intricate healthcare fraud schemes. Your investigations will aim to prevent the payment of fraudulent claims submitted to the Medicaid lines of business. You will research and prepare cases for clinical and legal review, document all appropriate case activity in the case tracking system, and facilitate feedback with providers related to clinical findings. You will also initiate proactive data mining to identify aberrant billing patterns, make referrals (internal and external) within 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 and guidance to less experienced ones, assist Investigators in identifying resources and the best course of action for investigations, and serve as backup to the Team Leader as necessary. You will cooperate with federal, state, and local 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. You will also give presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud, and provide input regarding controls for monitoring fraud-related issues within the business units.

Requirements

3+ years investigative experience in the area of healthcare fraud and abuse matters.
Working knowledge of medical coding; CPT, HCPCS, ICD10.
Experience with Microsoft Office with advanced skills in Excel (must know how to do pivot tables).
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs).

Nice To Haves

Previous Medicaid/Medicare investigatory 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.
Strong analytical and research skills.
Proficient in researching information and identifying information resources.
Strong verbal and written communication skills.
Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations).

Responsibilities

Conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse.
Handle sensitive or high-profile cases, complex cases involving multiple perpetrators or intricate healthcare fraud schemes.
Investigate to prevent payment of fraudulent claims submitted to the Medicaid lines of business.
Research and prepare cases for clinical and legal review.
Document all appropriate case activity in case tracking system.
Facilitate feedback with providers related to clinical findings.
Initiate proactive data mining to identify aberrant billing patterns.
Make referrals, both internal and external, in the required timeframe.
Facilitate the recovery of company and customer money lost as a result of fraud matters.
Provide on the job training to new Investigators and provide guidance for less experienced or skilled Investigators.
Assist Investigators in identifying resources and best course of action on investigations.
Serve as back up to the Team Leader as necessary.
Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
Give presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.
Provide input regarding controls for monitoring fraud related issues within the business units.