Analyst, Special Investigative Unit, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Customer Service

Contract Type:
Not provided

Salary:

43888.00 - 93574.00 USD / Year

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Job Description:

Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.

Job Responsibility:

Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse
Reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation
Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse
Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others
Facilitates the recovery of company and customer monetary losses
Provides input regarding controls for preventing or monitoring fraud related issues within the business units
Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
Maintains open communication with constituents within and external to the company
Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, and abuse
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in tracking system
Makes referrals, both internal and external, in the required timeframe

Requirements:

1-3 years of Investigative experience in the area of healthcare fraud, waste and abuse
Strong knowledge of medical terminology/CPT/HCPCS coding
Advanced skills with Microsoft Excel
Experience in healthcare/medical insurance claims investigation or professional/clinical experience
Background with law enforcement agencies involving economic or insurance related matters
or professional investigation experience involving economic or insurance related matters
or an authorized medical professional to evaluate medical related claims
Strong analytical and research skills
Proficient in researching information and identifying information resources
Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
Strong verbal and written communication skills
Strong customer service skills
Ability to interact with different groups of people at different levels and provide assistance on a timely basis
Ability to utilize company systems to obtain relevant electronic documentation

Nice to have:

AHFI, CFE, Certified Professional Coder
Knowledge of CVS/Aetna's policies and procedures
College degree in Criminal Justice or related field

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
August 20, 2025

Expiration:
September 15, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Analyst, Special Investigative Unit