Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health

2d•$46,988 - $102,000

About The Position

The Senior Investigator conducts high-level, complex investigations into known or suspected healthcare fraud and abuse, including sensitive or high-profile matters and cases involving multiple perpetrators or intricate schemes. The role investigates suspected fraud to prevent payment of fraudulent claims submitted to Medicaid lines of business, researches and prepares cases for clinical and legal review, documents activity in a case tracking system, and facilitates feedback to providers regarding clinical findings. The Senior Investigator also initiates proactive data mining to identify aberrant billing patterns, makes required referrals, and helps recover company and customer funds lost through fraud. The role provides on-the-job training and guidance to other Investigators, helps them identify resources and appropriate investigative approaches, and serves as a backup to the Team Leader as needed. It cooperates with law enforcement agencies in investigating and prosecuting healthcare fraud and abuse, demonstrates expertise in interactions and testimony during civil and criminal proceedings, presents to internal and external customers about healthcare fraud and Aetna’s approach, and provides input on business-unit controls for monitoring fraud-related issues. The position is full-time, with 40 anticipated weekly hours and travel of up to 10% depending on business needs.

Requirements

At least 3 years of investigative experience in healthcare fraud and abuse matters.
Working knowledge of medical coding, including CPT, HCPCS, and ICD-10.
Experience with Microsoft Office and advanced Excel skills, including pivot tables.
Ability to travel up to 10% (approximately 2–3 times per year, depending on business needs).
Bachelor’s degree or equivalent experience, defined as 3 or more years of working healthcare fraud, waste, and abuse investigations.

Nice To Haves

Previous Medicaid or Medicare investigatory experience.
Ability to exercise independent judgment and use available resources and technology to develop evidence and support fraud and abuse allegations.
Certification from the Association of Certified Fraud Examiners (CFE) or accreditation from the National Health Care Anti-Fraud Association (AHFI).
Knowledge of Aetna policies and procedures.
Knowledge and understanding of complex clinical issues.
Competence with legal theories.
Strong communication and customer service skills.
Ability to interact effectively with different groups and people at different levels in any situation.
Strong analytical and research skills.
Proficiency in researching information and identifying information resources.
Strong verbal and written communication skills.

Responsibilities

Conduct high-level, complex investigations of known or suspected healthcare fraud and abuse, including sensitive, high-profile, or multi-perpetrator cases and intricate schemes.
Investigate to prevent payment of fraudulent claims submitted to Medicaid lines of business.
Research and prepare cases for clinical and legal review.
Document appropriate case activity in the case tracking system.
Facilitate provider feedback related to clinical findings.
Initiate proactive data mining to identify aberrant billing patterns.
Make internal and external referrals within the required timeframe.
Facilitate recovery of company and customer money lost as a result of fraud matters.
Provide on-the-job training to new Investigators and guidance to less experienced or skilled Investigators.
Assist Investigators in identifying resources and the best course of action for investigations.
Serve as backup to the Team Leader as necessary.
Cooperate with federal, state, and local law enforcement agencies in healthcare fraud and abuse investigations and prosecutions.
Demonstrate expertise in interactions and provide testimony during civil and criminal proceedings.
Present to internal and external customers about healthcare fraud and Aetna’s approach to fighting fraud.
Provide input regarding controls for monitoring fraud-related issues within business units.