Senior Investigator-Special Investigations Unit (SIU) Job at CVS Health (Ohio)

Job Description

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Job Responsibility

Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases, or cases involving multiple perpetrators or intricate healthcare fraud schemes
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
Makes referrals, both internal and external, in the required timeframe
Facilitates the recovery of money lost as a result of fraud matters
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the manager as necessary
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 uni

Requirements

Must live in the state of Ohio
4+ years investigative experience in the area of healthcare fraud, waste and abuse matters
Working knowledge of medical coding
CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
The ability to understand and analyze health care claims and coding
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Bachelor's degree or equivalent experience

Nice to have

Previous Medicaid/Medicare investigatory experience
Previous Behavioral Health experience
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of Aetna's policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs

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Senior Investigator-Special Investigations Unit (SIU)

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