Senior Investigator (Dental, Aetna SIU)

CVS Health

1d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary We are seeking an experienced Senior Healthcare Fraud Investigator to join our Dental/Pharmacy/Broker Investigative Team within Aetna’s Special Investigations Unit. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA). This position will be focused on Dental Investigations.

Requirements

• 3-5 years of investigative experience in the area of healthcare fraud, waste and abuse.
• Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.
• Strong communication and customer service skills and the ability to effectively interact with Aetna's customers.
• Proficiency in Word, Excel, MS Outlook products, open source database search tools, social media and internet research.
• Ability to Travel for Business purposes.

Nice To Haves

• Certified Professional Coder (CPC), AHFI, CFE
• Bilingual English/Spanish
• Dental Investigative Experience
• Medicaid and Medicare experience

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.
• Researches and prepares cases for clinical and legal review.
• Documents 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.
• Facilitates the recovery of company and customer money lost as a result of fraud, waste and abuse.
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
• Demonstrates high level of knowledge and expertise during interactions with internal and external partners.
• Provide Trial Testimony in support of Criminal or Civil proceedings.
• Gives presentations to internal and external customers regarding ongoing case investigations.

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