Senior Healthcare Fraud Investigator (Aetna SIU)

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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

We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU). 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.
• 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 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 approximately 10% of time for business purposes.

Preferred Qualifications

• Preferred Location: FLORIDA
• Certified Professional Coder (CPC), AHFI, CFE
• Bilingual English/Spanish
• Dental Investigative experience
• Pharmacy Investigative experience
• Marketplace Broker Investigative experience
• Medicaid and Medicare experience
• Experience working with AHCA

Education

• Bachelor's degree or equivalent work experience.

Pay Range

The Typical Pay Range For This Role Is

$46,988.00 - $91,800.00

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 short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/17/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.