Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health

4d•$46,988 - $112,200•Remote

About The Position

We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), Self-Funded investigations team. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

Requirements

3-5 years investigative experience in the area of healthcare fraud, waste and abuse.
Experience in in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research.
Ability to travel approximately 10% of time for business purposes.

Nice To Haves

Certified Professional Coder (CPC), AHFI, CFE
Knowledge of CVS/Aetna's policies and procedures
Understanding of self-funded insurance plan operations
Strong communication and customer service skills and the ability to effectively interact with Aetna's customers
Resident of North Carolina

Responsibilities

Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse.
Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants, and customers.
Research and prepare cases for clinical and legal review.
Document all appropriate case activity in case tracking system.
Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse.
Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
Demonstrate high level of knowledge and expertise during interactions with internal and external partners.
Provide trial testimony in support of criminal or civil proceedings.
Give frequent presentations to internal and external customers regarding ongoing case investigations.
Respond quickly and accurately to questions and leads from internal and external customers.
Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.