Special Investigations Unit Senior Investigator (Aetna SIU)

CVS Health

3d

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 As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-lines of business, or cases involving multiple perpetrators or intricate healthcare fraud schemes. Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business Researches and prepares cases for clinical and legal review Documents all appropriate case activity in case tracking system Facilitates feedback with providers related to clinical findings Initiates proactive data mining to identify aberrant billing patterns Makes referrals, both internal and external, in the required timeframe Facilitates the recovery of company and customer money lost as a result of fraud matters Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators. Assists Investigators in identifying resources and best course of action on investigations Serves as back up to the Team Leader as necessary Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. 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 healthcare fraud matters and Aetna's approach to fighting fraud Provides input regarding controls for monitoring fraud related issues within the business units

Requirements

• 3-5 years investigative experience in the area of healthcare fraud and abuse matters.
• Working knowledge of medical coding; CPT, HCPCS, ICD10
• Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables).
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.
• 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.
• Bachelor's degree or equivalent experience (3-5 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.
• Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
• Researches and prepares cases for clinical and legal review
• Documents all appropriate case activity in case tracking system
• Facilitates feedback with providers related to clinical findings
• Initiates proactive data mining to identify aberrant billing patterns
• Makes referrals, both internal and external, in the required timeframe
• Facilitates the recovery of company and customer money lost as a result of fraud matters
• Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.
• Assists Investigators in identifying resources and best course of action on investigations
• Serves as back up to the Team Leader as necessary
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
• Provides input regarding controls for monitoring fraud related issues within the business units

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior