Senior Fraud & Waste Investigator
HumanaSalary not specified
Full Time
Senior (5 to 8 years), Expert & Leadership (9+ years)
[Remote] Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health
Connecticut, United States
Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
- 3-5 years investigative experience in the area of healthcare fraud, waste and abuse
- Experience in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research
- Ability to travel approximately 10% of the time for business purposes
- Bachelor's degree preferred or equivalent work experience
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 insureds, 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
- Exercise independent judgment and use available resources and technology to develop evidence in support of case investigations
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
What is the pay range for the Senior Investigator role?
The typical pay range for this role is $46,988.00 - $122,400.00, representing the base hourly rate or base pay.
Is this position remote or work from home?
This position can be work from home anywhere in the United States.
What are the required qualifications for this role?
Candidates need 3-5 years of investigative experience in healthcare fraud, waste, and abuse, experience with Microsoft Word, Excel, Outlook, open source database search tools, social media, and internet research, and the ability to travel approximately 10% of the time.
What is the work arrangement and hours for this position?
This is a full-time position with anticipated weekly hours of 40.
What makes a strong candidate for this Senior Investigator position?
Strong candidates will have 3-5 years of healthcare fraud investigation experience, proficiency in Microsoft Office and research tools, plus preferred qualifications like Certified Professional Coder (CPC), AHFI, CFE certifications, knowledge of CVS/Aetna policies, understanding of self-funded plans, and strong communication skills. A Bachelor's degree is preferred or equivalent work experience.
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.
Related Jobs
RemoteRemoteSenior SIU Desk Investigator (Remote, Contract)
AssuredSalary not specified
RemoteSenior Sanctions Investigator
MercurySalary not specified
RemoteSenior Fraud and Waste Investigator, Special Investigations Unit - Med…
HumanaSalary not specified