Senior Investigator, Special Investigations Unit (Aetna SIU)

health or multi-disciplinary provider groups in a prepayment environment

• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.

• Researches and prepares cases for clinical and legal review.

• Documents all appropriate case activity in case tracking system.

• Prepares and presents referrals, both internal and external, in the required timeframe.

• Facilitates the recovery of company lost as a result of fraud matters.

• Assists team in identifying resources and best course of action on investigations.

• 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.

• Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuseRequired Qualifications

• 3 years three years working on health care fraud, waste, and abuse investigatory and audits required.

• Knowledge of CPT/HCPCS/ICD coding

• Knowledge and understanding of clinical issues.

• Experience working in Microsoft Office products (Word, Excel, Outlook), Database search tools, and use in the Intranet/Internet to research information.

• Ability to effectively interact with different groups of people at different levels in any situation utilizing communication and customer service skills.

• Strong analytical and research skills using health care data.

• Proficient in researching information and identifying information resources.

• Ability to utilize company systems to obtain relevant electronic documentation.

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

Preferred Qualifications

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
• Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)
• Knowledge of Behavioral Health policies and procedures is a plus
• Experience working Behavioral Health fraud cases.
• Experience or knowledge working with state Medicaid agencies (ex: Department of Medicaid Services DMS).

Education

• A Bachelor's degree or an Associate's degree, with an additional three years (3 years total) working on health care fraud, waste, and abuse investigations and audits required.

Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$46,988.00 - $112,200.00This 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 peopleWe 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/benefitsWe anticipate the application window for this opening will close on: 05/16/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.