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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 - 112200.00 USD / Year
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Job Description:

The Senior Investigator role will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. This position will routinely handle high profile or highly sensitive matters involving cases that are national in scope, as well as, complex cases involving multi-lines of business, multiple subjects, or intricate healthcare fraud schemes.

Job Responsibility:

  • Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
  • Conduct thorough research on subject(s) and related entities
  • Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
  • Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
  • Research and prepare cases for both clinical and legal review
  • Collaborate with Medical Directors on clinical issues and medical record questions
  • Accurately documents all case activity and communications in designated case tracking system
  • Communicate clinical findings to provider
  • Adherent to all regulatory requirements
  • Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
  • Provide training and guidance to new and junior investigators
  • Assist junior Investigators in identifying resources for cases
  • offer suggestions on investigative strategy
  • Serve as back up to the Team Leader as necessary
  • Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
  • Experience in witness testimony
  • Proficient in testifying for both civil and criminal proceedings
  • Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
  • Strong communication skills, both written and oral, are necessary for the development and implementation of professional presentations for internal and external stakeholders regarding healthcare fraud matters and Enterprise approach to FWA
  • Communicate ideas on efficiency gains
  • provides input regarding controls for monitoring FWA among the business segments

Requirements:

  • 5+ years investigative experience in healthcare fraud and abuse matters
  • Working knowledge of medical coding
  • CPT, HCPCS, ICD10
  • Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables
  • Strong analytical ability to view and slice claims data in multiple facets
  • Self-starter: initiates research that will be vital to an investigation
  • Proficient in researching information and identifying new resources helpful to all cases
  • Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
  • Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Nice to have:

  • Medicaid/Medicare investigation experience
  • knowledge of applicable rules and regulations
  • Exercises independent judgement
  • uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
  • Credentials: Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI)
  • Knowledge of Aetna's policies and procedures/State and Federal requirements (internal applicants)
  • Knowledge and understanding of complex clinical issues
  • Competent with legal theories of FWA
  • Customer-Focused. Ability to effectively interact and collaborate with various stakeholders and departments to drive solution
  • Strong communication and customer service skills
What we offer:
  • Medical, dental, and vision coverage
  • paid time off
  • retirement savings options
  • wellness programs
  • bonus, commission or short-term incentive program

Additional Information:

Job Posted:
May 17, 2026

Expiration:
June 05, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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