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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

In addition:

- 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

Required Qualifications:

- 3-5 years investigative experience in the area of healthcare fraud and abuse matters.

- Working knowledge of medical coding; CPT, HCPCS, ICD10

- Strong analytical and research skills.

- Proficient in researching information and identifying information resources.

- Strong verbal and written communication skills

- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications:

- Previous Medicaid/Medicare investigatory experience

- Exercises independent judgement and uses available resources and
technology in developing evidence, supporting allegations of 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.
- Proficiency in Word, Excel, MS Outlook products, Database search tools, and the internet to research information

Education:

- Bachelor's degree or an additional 5 years of working health care fraud, waste and abuse investigations.

Pay Range

The typical pay range for this role is:

$46,988.00 - $112,200.00

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: 11/29/2024

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