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Investigator, Special Investigation Unit

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States , Charleston

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Category:
Customer Service

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Contract Type:
Not provided

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Salary:

43888.00 - 76500.00 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. 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.

Job Responsibility:

  • 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
  • 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
  • Interacts with different groups of people at different levels and provide assistance on a timely basis
  • Utilizes company systems to obtain relevant electronic documentation

Requirements:

  • Reside in West Virginia
  • 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
  • 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
  • Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice to have:

  • AHFI, CFE, Certified Professional Coder
  • Knowledge of CVS/Aetna's policies and procedures
  • Strong verbal and written communication skills
  • Strong customer service skills
What we offer:
  • Comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families
  • medical coverage
  • dental coverage
  • vision coverage
  • paid time off
  • retirement savings options
  • wellness programs

Additional Information:

Job Posted:
May 15, 2026

Expiration:
June 01, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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