Manager, Special Investigations, CVS Health

CVS Health

Location:
United States, Work at Home

Category:
Customer Service

Contract Type:
Employment contract

Salary:

60300.00 - 132600.00 USD / Year

Save Job

Apply Position

Job Description:

Direct oversight of SIU and Fraud, Waste and Abuse activities related to TX Medicaid and CHIP programs. Oversees activities related to the prevention, investigation, and prosecution of health care fraud and to recover lost funds. Responsible for compliance with state and federal regulations mandating the reporting of Texas fraud related activities and the preparation of the Texas Anti-Fraud Plan.

Job Responsibility:

Direct oversight of SIU and Fraud, Waste and Abuse activities related to TX Medicaid and CHIP programs
Oversees activities related to the prevention, investigation, and prosecution of health care fraud and to recover lost funds
Responsible for compliance with state and federal regulations mandating the reporting of Texas fraud related activities and the preparation of the Texas Anti-Fraud Plan
Leads a team of investigators to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse
Leads the 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
Manages workload of their team to ensure equitable distribution and exposure to wide range of cases
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
Participates in federal and state audits

Requirements:

5+ years of managing healthcare fraud, waste and abuse investigations and audits
3+ 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
Bachelors or equivalent experience

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, TX MCO Medicaid FWA Unit
Experience with Interpreting Contracts
Billing and Coding certifications such as CPC (AAPC)
Knowledge of Aetna's policies and procedures
Medicaid experience

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost 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:
November 14, 2025

Expiration:
November 22, 2025

Employment Type:

Fulltime

Work Type:

Remote work

View All Jobs In This Company

Job Link Share:

Manager, Special Investigations