Job Description

Senior Investigator, Aetna Special Investigations Unit

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, Aetna Special Investigations Unit, 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.

• 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
• Adherence 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
• Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
• Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
• 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

Required Qualifications

• 3+ 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 (pivot tables are a must, Power BI, etc.)
• 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
• Ability to travel up to 10%

Preferred Qualifications

• 5+ years investigative experience in healthcare fraud and abuse matters
• 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 and understanding of complex clinical issues
• Customer-Focused. Ability to effectively interact and collaborate with various stakeholders and departments to drive solution
• Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)

Education

• Bachelor's degree or equivalent experience (5+ of working health care fraud, waste and abuse investigations)

Anticipated Weekly Hours

40

Time Type

Full time

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

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.

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