Siu Investigator, CVS Health

CVS Health

Location:
United States, Oklahoma

Category:
Customer Service

Contract Type:
Employment contract

Salary:

Not provided

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Job Description:

As part of CVS Health, the role involves conducting investigations to address healthcare fraud, waste, and abuse, ensuring compliance with regulations, communicating with law enforcement agencies, and facilitating educational programs on fraud prevention and detection.

Job Responsibility:

Conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices
Conducts investigations of known or suspected acts of healthcare fraud and abuse
Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc.
Facilitates the recovery of company and customer money lost as a result of fraud matters
Provides input regarding controls for monitoring fraud related issues within the business units
Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
Maintains open communication with constituents within and external to the company
Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in tracking system
Makes referrals and deconflictions, both internal and external, in the required timeframe
Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations
Attending and presenting at quarterly state meetings

Requirements:

Must be located in Oklahoma
1+ years experience working in healthcare fraud, waste, and abuse investigations and audits
Experience reviewing and analyzing claims data to determine appropriate CPT and HCPCS code
Proficient in researching information and identifying information resources
Ability to interact with different groups of people at different levels and provide assistance on a timely basis
Proficiency in Word, Excel, MS Outlook products
Database search tools, and use in the Intranet/Internet to research information
Ability to utilize company systems to obtain relevant electronic documentation
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice to have:

Knowledge of Oklahoma Medicaid
Strong verbal and written communication skills
Strong customer service skills
Strong analytical and research skills
Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA)
Knowledge of Aetna's policies and procedures

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs including 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:
September 26, 2025

Expiration:
October 10, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Siu Investigator