Manager, Special Investigation

CVS Health Job Opportunity

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.

Position Summary

Oversees corporate activities related to the prevention, investigation, and prosecution of health care fraud to recover lost funds. Responsible for compliance with state and federal regulations mandating the reporting of corporate fraud-related activities and the preparation of the Corporate Anti-Fraud Plan.

What You Will Do

Leads a team of investigators and analysts to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and reporting; Medicaid experience is preferred. Leads a team in the planning and execution of investigations of acts of healthcare fraud and abuse by both members and providers. Provides direction and counsel on the handling of cases and facilitates issue resolution. Assists in identifying resources and best course of action to take in a timely and effective manner. Conducts case reviews and provides feedback to investigators on completeness and quality of the investigation. Conducts team member evaluations and provides performance feedback to staff on an ongoing basis. Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs. Assesses training needs and works with SIU Director on development plans for team members. Develops and maintains close working relationships with federal, state, and local law enforcement agencies in the investigation and prosecution of acts of healthcare fraud and abuse. Participates in state meetings. Ensures compliance with contractual requirements. Coordinates and collaborates with program integrity staff, compliance, and senior leadership. Contributes to the development and delivery of educational awareness and training programs that meet or exceed those required by state mandates. Participates in federal and state audits.

Required Qualifications

2 to 5 years of managing healthcare fraud, waste and abuse investigations and audits.

3 to 5 years of leadership experience

A minimum 3 years of experience in a Healthcare Program Integrity, Medicaid Special Investigation or Medicaid / Medicare / Commercial Compliance role

Strong verbal and written communication skills.

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

Proficient in researching information and identifying information resources.

Preferred Qualifications

Credentials such as a certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)

Experience In Medicaid Compliance, Medicaid Investigations, MCO Medicaid FWA Unit in the following States : Texas, Ohio, New York, and Oklahoma

Experience with Interpreting Contracts

Billing and Coding certifications such as CPC (AAPC)

Knowledge of Aetna's policies and procedures

Education

Bachelor's degree preferred / specialized training / relevant professional qualification

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is : $54,300.00 - $159,120.00

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 colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

We anticipate the application window for this opening will close on : 11 / 23 / 2025

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. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.