Senior Investigator, Special Investigations Unit (Aetna SIU)

Senior Healthcare Fraud Investigator

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. This position can be work from home anywhere in the United States.

Position Summary We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), dedicated to a specific self-funded plan sponsor. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

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.
• Research and prepare cases for clinical and legal review.
• Document 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.
• Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse.
• Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
• Demonstrate high level of knowledge and expertise during interactions with internal and external partners.
• Provide trial testimony in support of criminal or civil proceedings.
• Give frequent presentations to internal and external customers regarding ongoing case investigations.
• Respond quickly and accurately to questions and leads from internal and external customers.
• Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.

Required Qualifications

Preferred Qualifications

Education

Anticipated Weekly Hours 40

Time Type Full time

Pay Range The typical pay range for this role is : $46,988.00 - $122,400.00

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.

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 :

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer.