Senior Investigator (Dental, Aetna SIU)

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.

Position Summary
We are seeking an experienced Senior Healthcare Fraud Investigator to join our Dental/Pharmacy/Broker Investigative Team within Aetna’s Special Investigations Unit.  In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA). This position will be focused on Dental Investigations.

Key Responsibilities

• Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse.
• Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants and customers.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in case tracking system.
• Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
• Facilitates the recovery of company and customer money lost as a result of fraud, waste and abuse.
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
• Demonstrates high level of knowledge and expertise during interactions with internal and external partners.
• Provide Trial Testimony in support of Criminal or Civil proceedings.
• Gives presentations to internal and external customers regarding ongoing case investigations.

Required Qualifications

• 3-5 years of investigative experience in the area of healthcare fraud, waste and abuse.
• Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.
• Strong communication and customer service skills and the ability to effectively interact with Aetna's customers.
• Proficiency in Word, Excel, MS Outlook products, open source database search tools, social media and internet research.
• Ability to Travel for Business purposes.

Preferred Qualifications

• Certified Professional Coder (CPC), AHFI, CFE
• Bilingual English/Spanish 
• Dental Investigative Experience
• Medicaid and Medicare experience

Education

Bachelor's Degree in the following areas:

• Criminal Justice
• Healthcare Management
• Public Health
• Biological Sciences
• Data and Analytics
• Other related field

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$46,988.00 - $102,000.00

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our co