Senior Investigator, Special Investigations Unit (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.

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), Self-Funded investigations team.

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

• 3-5 years investigative experience in the area of healthcare fraud, waste and abuse.
• Experience in in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research.
• Ability to travel approximately 10% of time for business purposes.

Preferred Qualifications 

• Certified Professional Coder (CPC), AHFI, CFE
• Knowledge of CVS/Aetna's policies and procedures
• Understanding of self-funded insurance plan operations
• Strong communication and customer service skills and the ability to effectively interact with Aetna's customers

• Resident of North Carolina

Education

• Bachelor's degree preferred or equivalent work experience.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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