Manager, Special Investigation, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Customer Service

Contract Type:
Not provided

Salary:

54300.00 - 159120.00 USD / Year

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Job Description:

Oversees corporate activities related to the prevention, investigation, and prosecution of health care fraud to recover lost funds. Responsible for compliance with state and federal regulations mandating the reporting of corporate fraud-related activities and the preparation of the Corporate Anti-Fraud Plan.

Job Responsibility:

Leads a team of investigators and analysts 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 reporting
Leads a team in the planning and execution of investigations of acts of healthcare fraud and abuse by both members and providers
Provides direction and counsel on the handling of cases and facilitates issue resolution
Conducts case reviews and provides feedback to investigators on completeness and quality of the investigation
Conducts team member evaluations and provides performance feedback to staff on an ongoing basis
Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs
Assesses training needs and works with SIU Director on development plans for team members
Develops and maintains close working relationships with federal, state, and local law enforcement agencies in the investigation and prosecution of acts of healthcare fraud and abuse
Ensures compliance with contractual requirements
Coordinates and collaborates with program integrity staff, compliance, and senior leadership
Contributes to the development and delivery of educational awareness and training programs that meet or exceed those required by state mandates
Participates in federal and state audits

Requirements:

2 to 5 years of managing healthcare fraud, waste and abuse investigations and audits
3 to 5 years of leadership experience
A minimum 3 years of experience in a Healthcare Program Integrity, Medicaid Special Investigation or Medicaid / Medicare / Commercial Compliance role
Strong verbal and written communication skills
Ability to interact with different groups of people at different levels and provide assistance on a timely basis
Proficient in researching information and identifying information resources

Nice to have:

Credentials such as a certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Experience In Medicaid Compliance, Medicaid Investigations, MCO Medicaid FWA Unit in the following States: Texas, Ohio, New York, and Oklahoma
Experience with Interpreting Contracts
Billing and Coding certifications such as CPC (AAPC)
Knowledge of Aetna's policies and procedures

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and 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 01, 2025

Expiration:
September 28, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Manager, Special Investigation