Investigator, Special Investigations Unit (Aetna SIU) Job at CVS Health (Work at Home)

Job Description

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

Review concern/allegation, develop an investigation plan, identify additional information needed, and individuals to interview
Manage an active caseload ensuring timely and thorough task completions while adhering to legal and organizational standards
Interview healthcare providers, patients/members, and others to gather information pertinent to the investigation
Use data analytics and software tools to analyze billing patterns, identify anomalies, and detect suspicious activities
Use medical records, billing data, and coding systems to ensure compliance with regulations and code requirements
Partner with the Senior Investigator, as needed, to support FWA case activities and ensure alignment on investigative strategy and next steps
Partner with the Clinical team to support pre-payment and post-payment coding reviews
Collaborate with SIU Compliance and PI Managers for specific state requirements and deliverables
Refer cases to law enforcement and regulatory agencies as required by state plans
Coordinate with internal legal teams to review findings, case outcomes, prepare evidence for potential court cases or administrative hearings
Prepare comprehensive investigation reports that document fact findings and provide recommendations for appropriate corrective action outcomes
Maintain and document accurate records of all investigations, including evidence collected, interviews, and outcomes
Monitor and promote healthcare provider adherence to applicable federal and state requirements, as well as payer billing and claims guidelines
Communicate case outcomes to healthcare providers and complete follow-up outreach as needed

Requirements

Must reside in Oklahoma
Experience in working healthcare investigations
2 years of experience in healthcare fraud investigation
Experience with using fraud, waste, and abuse (FWA) detection tools and enterprise databases to support data mining, analysis, and information gathering
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice to have

Credential(s) such as Certified Fraud Examiners (CFE) and National Health Care Anti-Fraud Association (AHFI)
3+ years Medicaid Fraud, Waste and Abuse investigatory experience
Coding certification such as CPC (AAPC) and/or CCS (AHIMA)
Knowledge of Behavioral Health care delivery, policies and procedures, and contractual implications
Knowledge of healthcare laws, regulations, and CPT/HCPCS coding
Strong analytical and investigative skills
Strong communication skills needed for interviewing and presentations to Health Plans and State Regulators
Strong documentation/writing skills needed for presentations and case documentation

What we offer

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
bonus, commission or short-term incentive program

CVS Health - All Job Offers

Select Country

Investigator, Special Investigations Unit (Aetna SIU)

Job Description

Job Responsibility

Requirements

Nice to have

What we offer

Looking for more opportunities?

Investigator, Special Investigations Unit (Aetna SIU)

Senior Investigator, Special Investigations Unit (Aetna SIU)

Vice President

Customer Assistant II

Care Assistant - Days

DPW Highway Equipment Operator

Grant Accountant

Hgv Class 1 Driver

Financial Advisor

Our AI answers in your language