Special Investigations Unit Senior Investigator

CVS Health•Work At Home-Massachusetts, MA

1d•Remote

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 The Senior Investigator role will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. This position will routinely handle high profile or highly sensitive matters involving cases that are national in scope, as well as, complex cases involving multi-lines of business, multiple subjects, or intricate healthcare fraud schemes.

Requirements

5+ years investigative experience in healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables.
Strong analytical ability to view and slice claims data in multiple facets
Self-starter: initiates research that will be vital to an investigation
Proficient in researching information and identifying new resources helpful to all cases
Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Nice To Haves

Medicaid/Medicare investigation experience; knowledge of applicable rules and regulations
Exercises independent judgement; uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials: Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI)
Knowledge of Aetna's policies and procedures/State and Federal requirements (internal applicants)
Knowledge and understanding of complex clinical issues
Competent with legal theories of FWA
Customer-Focused. Ability to effectively interact and collaborate with various stakeholders and departments to drive solution
Strong communication and customer service skills

Responsibilities

Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
Conduct thorough research on subject(s) and related entities
Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
Research and prepare cases for both clinical and legal review
Collaborate with Medical Directors on clinical issues and medical record questions
Accurately documents all case activity and communications in designated case tracking system
Communicate clinical findings to provider
Adherent to all regulatory requirements
Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
Provide training and guidance to new and junior investigators
Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy
Serve as back up to the Team Leader as necessary
Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
Strong communication skills, both written and oral, are necessary for the development and implementation of professional presentations for internal and external stakeholders regarding healthcare fraud matters and Enterprise approach to FWA
Communicate ideas on efficiency gains; provides input regarding controls for monitoring FWA among the business segments