The SIU Investigator conducts complex investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.

What you will do
- Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment
- Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
- Researches and prepares cases for clinical and legal review.
- Documents all appropriate case activity in case tracking system.
- Prepares and presents referrals, both internal and external, in the required timeframe.
- Facilitates the recovery of company lost as a result of fraud matters.
- Assists team in identifying resources and best course of action on investigations.
- 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.
- Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse

Required Qualifications

• 3 years working on health care fraud, waste, and abuse investigatory and audits required.
• Knowledge of CPT/HCPCS/ICD coding
• Knowledge and understanding of clinical issues.
• Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
• Strong communication and customer service skills.
• Ability to effectively interact with different groups of people at different levels in any situation.
• Strong analytical and research skills using health care data.
• Proficient in researching information and identifying information resources.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
• Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)
• Knowledge of Behavioral Health policies and procedures is a plus
• Experience working Behavioral Health fraud cases

Education

• Bachelor's degree, or an Associate's degree, with an additional three years (3 years total) working on health care fraud, waste, and abuse investigations and audits required.

Pay Range

The typical pay range for this role is:

$46,988.00 - $122,400.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/13/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.