Job Description

Senior Healthcare Fraud Investigator

At CVS Health, we are building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. This position can be work from home anywhere in the United States. We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), dedicated to a specific self-funded plan sponsor. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

Key responsibilities include conducting high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse, preventing payment of suspect or fraudulent claims, researching and preparing cases for clinical and legal review, documenting all appropriate case activity in case tracking system, preparing written case summaries and making referrals to State and Federal Agencies within the timeframes required by Law, facilitating the recovery of company and customer money lost as a result of fraud, waste and abuse, cooperating with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud, demonstrating high level of knowledge and expertise during interactions with internal and external partners, providing trial testimony in support of criminal or civil proceedings, giving frequent presentations to internal and external customers regarding ongoing case investigations, responding quickly and accurately to questions and leads from internal and external customers, and exercising independent judgment and using available resources and technology to develop evidence in support of case investigations.

Required qualifications include 3-5 years investigative experience in the area of healthcare fraud, waste and abuse, experience in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research, and ability to travel approximately 10% of time for business purposes. Preferred qualifications include 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. A Bachelor's degree is preferred or equivalent work experience.

Anticipated weekly hours are 40 and time type is full time. The pay range for this role is $46,988.00 - $122,400.00. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues include wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions 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.

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