Investigator, Special Investigations Unit, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Not provided

Salary:

43888.00 - 93574.00 USD / Year

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Job Description:

The SIU Investigator conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.

Job Responsibility:

Routinely handles cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment
Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Prepares and presents referrals, both internal and external, in the required timeframe
Facilitates the recovery of company lost as a result of fraud matters
Assists team in identifying resources and best course of action on investigations
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
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse

Requirements:

1 year experience working on health care fraud, waste, and abuse investigatory and audits required
Knowledge of CPT/HCPCS/ICD coding
Knowledge and understanding of clinical issues
Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation
Strong analytical and research skills using health care data
Proficient in researching information and identifying information resources
Ability to utilize company systems to obtain relevant electronic documentation
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice to have:

1-3 years experience working on health care fraud, waste, and abuse investigations and audits required or equivalent investigations experience
Illinois residency
Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience
Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)
Knowledge of Behavioral Health policies and procedures is a plus
Experience working Behavioral Health fraud cases

What we offer:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Additional Information:

Job Posted:
June 13, 2025

Expiration:
June 27, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Investigator, Special Investigations Unit