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Special Investigations Unit Senior Investigator

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States , Work at Home

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Category:
-

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Contract Type:
Not provided

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Salary:

46988.00 - 91800.00 USD / Year
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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
  • 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
  • Serves as back up to the Team Leader 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 units

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)

Nice to have:

  • Previous Medicaid/Medicare investigatory 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:
  • 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
  • Retiree medical access

Additional Information:

Job Posted:
February 22, 2026

Expiration:
March 04, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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