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Senior Healthcare Fraud Investigator

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States

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Category:
Customer Service

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Contract Type:
Not provided

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Salary:

46988.00 - 122400.00 USD / Year
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Job Description:

Senior Healthcare Fraud Investigator position in the Special Investigations Unit (Aetna SIU) dedicated to a specific self-funded plan sponsor, managing complex investigations into suspected and known acts of healthcare fraud, waste and abuse

Job Responsibility:

  • Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse
  • Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants, and customers
  • Research and prepare cases for clinical and legal review
  • Document all appropriate case activity in case tracking system
  • Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law
  • Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse
  • Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud
  • Demonstrate high level of knowledge and expertise during interactions with internal and external partners
  • Provide trial testimony in support of criminal or civil proceedings
  • Give frequent presentations to internal and external customers regarding ongoing case investigations
  • Respond quickly and accurately to questions and leads from internal and external customers
  • Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations

Requirements:

  • 3-5 years investigative experience in the area of healthcare fraud, waste and abuse
  • Experience in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research
  • Ability to travel approximately 10% of time for business purposes
  • Bachelor's degree preferred or equivalent work experience

Nice to have:

  • Certified Professional Coder (CPC), AHFI, CFE
  • Knowledge of CVS/Aetna's policies and procedures
  • Understanding of self-funded insurance plan operations
  • Strong communication and customer service skills and the ability to effectively interact with Aetna's customers
What we offer:
  • Affordable medical plan options
  • 401(k) plan with matching company contributions
  • Employee stock purchase plan
  • 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:
November 17, 2025

Expiration:
January 03, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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