Medical Director - SIU (Special Investigations Unit)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Medical Director - SIU (Special Investigations Unit)

CVS Health - Special Investigations Unit (SIU) 

Join our mission to safeguard healthcare integrity and protect patient well-being. As the Medical Director of Healthcare Fraud Investigations, you'll lead our efforts to detect, prevent, and combat fraudulent activities in the healthcare system. 

**This is a remote based, work from home role.**

Key Responsibilities: 

The Special Investigations Unit (SIU) Medical Director will be responsible for performing reviews of medical records in support of healthcare fraud investigations.  Serving as a clinical liaison supporting SIU activities across all lines of business the SIU Medical Director will be responsible for making both pre and post-payment claim payment determinations based on Aetna Clinical Policy and/or state and federal regulations.  Additional responsibilities include:   

• Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors in matters pertaining to the investigation of suspected healthcare fraud cases  

• Develops and delivers presentations to internal and external customers regarding healthcare fraud matters and Aetna’s approach to fighting fraud.   

• Provides clinical expertise and business direction in the creation of analytical solutions designed to identify potentially fraudulent scenarios 

• Maintains open communication with constituents within and external to the organization 

• Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, or abuse 

• Documents all appropriate information related to medical review determinations 

• Proactively builds relationships with other internal MDs to obtain clinical guidance when required to ensure accurate decision making 

• Represents Aetna as a witness in legal matters as required, and as approved by the Legal Department.  Demonstrates high level of knowledge and acts confidently when providing testimony during civil or criminal proceedings. 

• Responsible for peer to peer reviews of SIU related claims based on provider escalation or state/federal requirements   

• Supports legal efforts by providing expert medical testimony and  

• Conducts root cause analysis to identify potential control gaps in the organization’s existing clinical policy, procedures, claim editing etc., and proactively seeks out appropriate contacts to help implement solutions. 

• Mentor and educate SIU team members on clinical aspects of fraud schemes 

Required Qualificatio