Analyst, Special Investigation Unit

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT)

Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.

Fundamental Components:

- Conducts investigations of known or suspected acts of healthcare fraud, waste, 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, abusive, or otherwise improperly billed claims submitted by providers, members, and others

- Facilitates the recovery of company and customer monetary losses

- Provides input regarding controls for preventing or 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, waste, and abuse

- Researches and prepares cases for clinical and legal review

- Documents all appropriate case activity in tracking system

- Makes referrals, both internal and external, in the required timeframe

- Exhibits behaviors outlined in Employee Competencies

- Exhibits behaviors outlined in SIU Investigator Competencies

- May include travel to testify in court proceedings or training if necessary

Required Qualifications

Investigative experience in the area of healthcare fraud, waste and abuse

- Strong knowledge of medical terminology/CPT/HCPCS coding.

- Advanced skills with Microsoft Excel

- Experience in healthcare/medical insurance claims investigation or professional/clinical experience

- Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims

- Strong analytical and research skills

- Proficient in researching information and identifying information resources

- Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information

- Strong verbal and written communication skills

- Strong customer service skills

- Ability to interact with different groups of people at different levels and provide assistance on a timely basis

- Ability to utilize company systems to obtain relevant electronic documentation

Preferred Qualifications

AHFI, CFE, Certified Professional Coder

Knowledge of CVS/Aetna's policies and procedures
 

Education

College degree in Criminal Justice or related field

Pay Range

The typical pay range for this role is:

$40,600.00 - $89,300.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and