Senior Investigator, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Customer Service

Contract Type:
Employment contract

Salary:

46988.00 - 91800.00 USD / Year

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Job Description:

Senior Investigator position conducting complex investigations of healthcare fraud and abuse for Aetna SIU, focusing on preventing payment of fraudulent claims, working with law enforcement, and providing training to other investigators.

Job Responsibility:

Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
Investigate to prevent payment of fraudulent claims submitted to Medicaid lines of business
Research and prepare cases for clinical and legal review
Document all appropriate case activity in case tracking system
Facilitate feedback with providers related to clinical findings
Initiate proactive data mining to identify aberrant billing patterns
Make referrals, both internal and external
Facilitate recovery of company and customer money lost due to fraud
Provide on the job training to new Investigators
Cooperate with federal, state, and local law enforcement agencies
Provide testimony during civil and criminal proceedings
Give presentations regarding healthcare fraud matters

Requirements:

WEST VIRGINIA RESIDENCY REQUIRED
3-5 years investigative experience in healthcare fraud and abuse matters
Working knowledge of medical coding: CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
Ability to travel up to 10% (approx. 2-3x per year)
Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations)

Nice to have:

Previous Medicaid/Medicare investigatory experience
Certification from the Association of Certified Fraud Examiners (CFE)
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

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
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:
September 12, 2025

Expiration:
October 09, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Investigator