Senior Healthcare Fraud Investigator, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Not provided

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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Senior Healthcare Fraud Investigator