Senior Investigator, Special Investigations Unit (SIU)

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.

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:

As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-lines of business, or cases involving multiple
perpetrators or intricate healthcare fraud schemes

- 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

In addition:

- 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

Required Qualifications:

- 3-5 years investigative experience in the area of healthcare fraud and abuse matters.

- Working knowledge of medical coding; CPT, HCPCS, ICD10

- Strong analytical and research skills.

- Proficient in researching information and identifying information resources.

- Strong verbal and written communication skills

- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications:

- Previous Medicaid/Medicare investigatory experience

- Exercises independent judgement and uses available resources and
technology in developing evidence, supporting allegations of 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.
- Proficiency in Word, Excel, MS Outlook products, Database search tools, and the internet to research information

Education:

- Bachelor's degree or an additional 5 years of working health care fraud, waste and abuse investigations.

Pay Range

The typical pay range for this role is: