Manager, Special Investigations (Aetna SIU) at CVS Health

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, InsuranceIndustries

Requirements

5+ years of managing healthcare fraud, waste and abuse investigations and audits
3+ 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
Bachelor's or equivalent experience

Responsibilities

Direct oversight of SIU and Fraud, Waste and Abuse activities related to TX Medicaid and CHIP programs
Oversees activities related to the prevention, investigation, and prosecution of health care fraud and to recover lost funds
Responsible for compliance with state and federal regulations mandating the reporting of Texas fraud related activities and the preparation of the Texas Anti-Fraud Plan
Leads a team of investigators 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
Leads the 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

Skills

SIU

Fraud Investigation

Healthcare Fraud

Medicaid

CHIP

Fraud Prevention

Case Management

Team Leadership

Compliance

Regulatory Reporting

Performance Evaluation

Training Development

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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