Fraud and Waste Investigator
HumanaSalary not specified
Full Time
Junior (1 to 2 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
Candidates must have 3-5 years of investigative experience in healthcare fraud, waste, and abuse, with proficiency in Word, Excel, MS Outlook, and various online research tools. A Bachelor's degree or equivalent professional experience is required, and the ability to travel approximately 10% of the time is necessary. Preferred qualifications include CPC, AHFI, CFE certifications, bilingual English/Spanish skills, and experience in dental, pharmacy, Marketplace Broker, Medicaid, or Medicare investigations.
Responsibilities
The Senior Healthcare Fraud Investigator will manage complex investigations into suspected healthcare fraud, waste, and abuse to prevent fraudulent claim payments. Responsibilities include researching and preparing cases for review, documenting all case activity, preparing written summaries, and making referrals to state and federal agencies. The role also involves facilitating the recovery of funds lost to fraud, cooperating with law enforcement, providing expert testimony, and presenting case investigations to internal and external partners.
Skills
Healthcare Fraud Investigation
Fraud, Waste, and Abuse (FWA)
Claim Investigation
Case Documentation
Legal Referrals
Law Enforcement Cooperation
Trial Testimony
Presentation Skills
Independent Judgment
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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