Special Investigations Unit Senior Investigator Job at CVS Health

Senior Manager, Internal Investigation

The Department of Investigations is a subgroup of the Global Safety & Security (...

Location

China , Shanghai

Salary:

Not provided

Marriott Bonvoy

Expiration Date

Until further notice

Requirements

B.S. degree and/or relevant experience
At least 8 years of progressive Investigation or Audit experience
Identifying and analyzing case evidence before constructing an effective interview plan
Investigative interview skills within local employment law requirements
Experienced undercover investigation/project management skills
Demonstrated hotel operations/management experience
Strong operational experience in Asia Pacific including Greater China
Ability to read, write and communicate fluently in both English & Mandarin
Demonstrated investigative development skills
In-depth knowledge of Internal Investigations services

Job Responsibility

Manage or directly provide specific investigative services, projects and information
Manage outside vendors for undercover investigations
Influence internal management regarding employment actions resulting from theft, drug abuse, fraud or serious misconduct
Provide on-site closure of investigations to legally defendable conclusions
Manage or deliver technical, legal and communication requirements for covert electronic video surveillance
Access and manage process of publicly held information for due diligence analysis
Provide direct on-site unit assistance for property specific investigations
Gather and coordinate information
Provide technical expertise in investigative interviews
Respond to and support MI requests for specialized investigative direction

Fulltime

New

Special Investigations Unit Senior Investigator

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Work at Home

Salary:

46988.00 - 91800.00 USD / Year

CVS Health

Expiration Date

March 04, 2026

Requirements

LOUISIANA RESIDENCY REQUIRED
3+ years investigative experience in the area of healthcare fraud 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
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations)

Job Responsibility

Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
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 company and customer 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

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues 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

Fulltime

!

Director, Compliance on Special Investigations Unit and Fraud, Waste and Abuse

The Director, Compliance on Special Investigations and Fraud, Waste and Abuse (F...

Location

United States , Los Angeles

Salary:

135136.00 - 216218.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Bachelor's Degree in Criminal Justice or Related Field
At least 7 years of experience in healthcare compliance, fraud investigations, law enforcement, or related field
At least 5 years of experience in leading teams, projects, initiatives, or cross-functional groups
Demonstrated experience managing complex investigations in a managed care or healthcare environment
Experience in coordinating with external regulators and law enforcement agencies
Proven knowledge of CMS, DHCS, DMHC, OIG, and DOJ regulatory frameworks governing FWA programs
Strong investigative skills, including evidence gathering, interviewing, and case documentation
Demonstrated success in leading complex, multi-party investigations with integrity and discretion
Excellent communication skills
Strong organizational and project management abilities

Job Responsibility

Lead L.A. Care’s Special Investigations Unit (SIU) in overseeing internal and external investigations into fraud, waste, abuse, and compliance violations
Drive the design, implementation, and continuous improvement of the Fraud, Waste, and Abuse (FWA) program
Ensure effective case intake, triage, investigation, tracking, and resolution processes
Develop and support enterprise policies, procedures, and training programs supporting FWA prevention, detection, and response
Direct and oversee investigations into allegations of non-compliance, ethical violations, or fraudulent behavior
Partner with Legal, Compliance, and Human Resources on sensitive internal investigations
Ensure timely and accurate reporting of SIU/FWA activity to external agencies
Lead enterprise readiness for external audits, regulatory inquiries, and enforcement actions
Conduct strategic planning to use resources to meet departmental and Enterprise-wide goals
Monitor investigative trends, emerging risks, and regulatory developments

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Senior Director of Operations - PACE

Advance Your Career in Insurance Claims with Allied Universal® Compliance and In...

Location

United States , Dallas

Salary:

Not provided

Allied Universal®

Expiration Date

Until further notice

Requirements

Must possess one of the following: Bachelor’s degree in Healthcare Administration, Nursing, or Business
Associate’s degree in Healthcare Administration, Nursing, or Business and a minimum of eight (8) years of related experience in a healthcare leadership role
Minimum of three (3) years managing or directing an SIU insurance investigation program
Minimum of six (6) years of experience in a progressive healthcare leadership role
Ability to think strategically, make timely decisions and implement change
Ability to remain highly productive in a changing environment, possess strong attention to detail and well-developed organizational skills, and maintain a high level of discretion
Demonstrated proficiency in using subscription databases to search for relevant information on investigative assignments in support of the technical and professional staff of the SIU
Outstanding written and oral communication skills
Proficiency in Microsoft Outlook, Excel, Word, and PowerPoint

Job Responsibility

Oversight of SIU (Special Investigative Unit) Investigations team associated with the PACE contract
Use independent judgment to define and confirm client objectives (including due dates) on all new, reopen, and investigative referral cases
Provide consultation to the client using independent discretion to develop and implement an efficient, effective, and ethical investigation of an insurance claim
Ensure adherence to clear guidelines regarding company policies on privacy, compliance, and ethics
Ensure independently that the investigators assigned to complete the investigative tasks requested by the client have been given clear instruction on the client’s expectations at the time the case is approved
Maintain quality control after investigation is completed, ensuring that all client’s objectives have been addressed and achieved, and the billing applied to this work product falls within the standard billing schedule or client contract rates
Ensure team meets “reopen” sales goals on a monthly basis, creating accurate funding records for all items billable to the client
Use sound management, discretion, and independent judgment to resolve conflicts between clients and/or investigators
Handle customer complaints (negotiating as needed) and forward field operational issues to appropriate Vice President as needed
Provide daily updates to the clients within one business day after an investigative task has been completed, or per the client’s updating protocols set forth in a contract (if applicable)

What we offer

Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
Seven paid holidays annually, sick days available where required by law
Vacation time offered at an initial accrual rate of 3.08 hours biweekly for full time positions. Unused vacation is only paid out where required by law
Employee Assistance Program
Employee Discount Program
Tuition Discount Program
Training & Career Development Programs

Fulltime

Enhanced Staff Nurse & Enhanced Senior Staff Nurse

The role is responsible for the provision of quality service in line with standa...

Location

Ireland , Lucan, Co. Dublin

Salary:

Not provided

Blackrock Health Hermitage Clinic

Expiration Date

Until further notice

Requirements

Be registered in the general division of the Register of Nurses maintained by NMBI
Meet the qualifying conditions of Documented completion of clinical competencies in relation to patient care / speciality area ( Unit Competency Folder)
Evidence of ongoing personal professional development, ( Unit Competency Folder)
Completion of Mandatory Training
Evidence of participation in audit and evaluation , including collection of Quality care data or metrics
Competency in cannulation in all Hermitage Clinic nursing units, Administration of 1st Dose Antibiotics, ECG , Bladder Scanning
Flexibility to transfer or undertake rotation within the unit or between the patient care units
Submission of your annual registration with the Nursing and Midwifery Board of Ireland to the Hermitage Clinic
Ongoing skills training – relevant to care required for patient load
Have at least 17 years recent relevant post-registration nursing experience (full-time or equivalent hours part-time) in an acute hospital setting (for Enhanced Senior Staff Nurse)

Job Responsibility

Practice Nursing according to the Code of Professional Conduct as laid down by Nursing and Midwifery Board of Ireland (NMBI) (Cnáimhseachais na hÉireann) Professional Clinical Guidelines and Code of Professional Conduct and Ethics
Take measures to develop and maintain clinical competence necessary for professional and contemporary nursing practice
Contribute to the development of an expanded scope of nursing practice
Maintain a high standard of professional behaviour and be accountable for own practice
Be aware of ethical policies and procedures which pertain to area of practice
Engage with redeployment when deemed necessary by senior nursing management for service continuity, service provision and patient safety
Adhere to NMBI Guidance on Medication Administration
Ensure that controlled drug records are kept in accordance with standard recognised legal and professional practice
Keep accurate, comprehensive, up-dated records and written reports as required and guided by NMBI recommendations
Document all necessary assessments, interventions and care provided on the Meditech Patient information system

Fulltime

New

Executive Director, Clinical Health Services - Mental Well-being

At Aetna, our health benefits business, we are committed to helping our members ...

Location

United States , Work at Home

Salary:

184112.00 - 396550.00 USD / Year

CVS Health

Expiration Date

February 27, 2026

Requirements

10-15 years of population health experience including Total Cost of Care analysis, clinical strategy, clinical operations leadership, and value-based behavioral health initiatives
10+ years of experience working with behavioral health products
Strong ability to interpret analytics, guide data design, and present outcomes to internal and external stakeholders
Experience partnering with sales teams on finalist presentations, providing clinical expertise and addressing customer questions
Proven experience collaborating with senior clinical leadership to maintain standards and policies
Demonstrated success in developing strategies that improve access, quality, and affordability of care
Knowledge of HEDIS and NCQA quality measures with experience applying mental health expertise to these initiatives
Skilled in influencing senior leaders, building consensus, and driving strategic initiatives in complex, matrixed organizations
Experienced public speaker with direct engagement across customers, business leaders, and industry forums
Ability to evaluate mental well-being vendors and contribute to research and peer-reviewed publications

Job Responsibility

Support sales teams in finalist presentations by addressing clinical questions and explaining the care model
Collaborate with Clinical Operations (Employee Assistance Programs, Resources for Living, and On-Demand teams) and the Office of Health Care Affordability (OHCA) to advance affordability initiatives and adhere to specific, measurable actions tied to performance goals or compliance standards that are evaluated and scored (SAIs)
Analyze cost trends and work with network teams, Special Investigations Units, and other stakeholders to reduce costs and improve outcomes
Represent Aetna Mental Well-being at industry events, presenting analytics, clinical insights, and thought leadership on mental health and overall well-being
Partner with Aetna’s Performance Excellence Quality (PEQ) team to guide analytics design, interpret results, and present outcomes data to customers and industry leaders
Ensure efficient, effective delivery of healthcare services in collaboration with clinical operations
Work with senior clinical leadership, including the Chief Psychiatric Officer and Chief Medical Officer, to maintain clinical standards and policies
Develop strategies to improve member access, care quality, and affordability
Provide mental health expertise for HEDIS and NCQA initiatives in partnership with Quality teams
Offer clinical input for evaluating mental well-being vendors

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
employee stock purchase plan
No-cost programs for all colleagues 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

Fulltime

!

Compliance Sanctions Senior Analyst

Serves as a senior compliance risk analyst for Independent Compliance Risk Manag...

Location

Malaysia , Kuala Lumpur

Salary:

Not provided

Citi

Expiration Date

Until further notice

Requirements

Preferably expertise of Sanctions and AML regulations, risks and typologies
Solid years of relevant experience
Knowledge of Compliance laws, rules, regulations, risks and typologies
Excellent written and verbal communication skills
Must be a self-starter, flexible, innovative and adaptive
Strong interpersonal skills with the ability to work collaboratively and with people at all levels of the organization
Work collaboratively with regional and global partners in other functional units
ability to navigate a complex organization
Excellent project management and organizational skills and capability to handle multiple projects at one time
Proficient in MS Office applications (Excel, Word, PowerPoint)

Job Responsibility

Analyzing comparative data, preparing and presenting regional and global reports related to sanctions risk assessments, and monitoring of sanctions related issues and escalations with senior management and global partners
Review, investigate and provide the final disposition of potential sanctions-related concerns that occur in account, relationship, securities holding, or transactions
Prepare and support all OFAC required reporting (e.g., OFAC Blocked and Rejected transactions, Annual Reporting of Blocked Property, reporting pursuant to general or specific licenses, as required)
Supporting a specialized team of Independent Compliance Risk (ICRM) officers responsible for program execution activities
Contributing to the design and maintenance of a comprehensive written ICRM Sanctions Framework (standards and policies)
Partnering with functional partners and key stakeholders – regionally and globally, as applicable, to ensure potential risks are identified during due diligence, or escalated on an ad hoc basis, are appropriately vetted and addressed
Identifying and escalating to the Chief Sanctions Officer material risks and significant instances of not adherence to the Framework by accountable front line units
directs investigations in coordination with GIU, CSIS, Legal, HR, or as appropriate
Monitoring adherence to Citi’s Global Sanctions Policy and relevant procedures
staying current on key Sanctions regulatory changes, key enforcement actions and related industry trends

What we offer

Citi provides programs and services for your physical and mental well-being including access to telehealth options, health advocates, confidential counseling and more
Citi provides access to an array of learning and development resources to help broaden and deepen your skills and knowledge as your career progresses
We have a variety of programs that help employees balance their work and life

Fulltime

Sanctions Senior Analyst

Serves as a senior compliance risk analyst for Independent Compliance Risk Manag...

Location

Ireland , Dublin

Salary:

Not provided

Citi

Expiration Date

Until further notice

Requirements

Expertise of AML and Sanctions regulations, risks and typologies
Knowledge of Compliance laws, rules, regulations, risks and typologies
Excellent written and verbal communication skills
Must be a self-starter, flexible, innovative and adaptive
Strong interpersonal skills with the ability to work collaboratively and with people at all levels of the organization
Work collaboratively with regional and global partners in other functional units
ability to navigate a complex organization
Excellent project management and organizational skills and capability to handle multiple projects at one time
Proficient in MS Office applications (Excel, Word, PowerPoint)
Knowledge in area of focus

Job Responsibility

Analyzing comparative data, preparing and presenting regional and global reports related to sanctions risk assessments, and monitoring of sanctions related issues and escalations with senior management and global partners
Supporting a specialized team of Independent Compliance Risk (ICRM) officers responsible for program execution activities
Contributing to the design and maintenance of a comprehensive written ICRM Sanctions Framework (standards and policies)
Partnering with functional partners and key stakeholders – regionally and globally, as applicable, to ensure potential risks are identified during due diligence, or escalated on an ad hoc basis, are appropriately vetted and addressed
Identifying and escalating to the Chief Sanctions Officer material risks and significant instances of not adherence to the Framework by accountable front line units
directs investigations in coordination with GIU, CSIS, Legal, HR, or as appropriate
Monitoring adherence to Citi’s Global Sanctions Policy and relevant procedures
staying current on key Sanctions regulatory changes, key enforcement actions and related industry trends
Overseeing adherence to procedures and processes, to ensure compliance with policies ensuring that front line units meet required standards
Interacting with relevant teams to raise awareness of Sanctions trends, emerging issues, remedial actions or enhancements to the program

What we offer

Citi is an equal opportunity employer
Accommodation for individuals with disabilities

Fulltime

Special Investigations Unit Senior Investigator

CVS Health

Location:
United States

Category:
-

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 25, 2026

Expiration:
March 24, 2026

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