Investigator, Special Investigations Unit (Aetna SIU)

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.Position Summary

This position can be work from home anywhere in the United States. Must be flexible to work CT hours (8:00 am - 5 pm CT)

Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.What you will do:

• Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
• Researches and prepares cases for clinical and legal review
• Documents all appropriate case activity in case tracking system
• Facilitates feedback with providers related to clinical findings
• Initiates proactive data mining to identify aberrant billing patterns
• Makes referrals, both internal and external, in the required timeframe
• Facilitates the recovery of company and customer money lost as a result of fraud matters
• Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.
• Assists Investigators in identifying resources and best course of action on investigations
• Serves as back up to the Team Leader as necessary
• 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

Required Qualifications

• 1-3 years of Investigative experience in the area of healthcare fraud, waste and abuse
• Strong knowledge of medical terminology/CPT/HCPCS coding.
• Advanced skills with Microsoft Excel
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience
• Proficient in researching information and identifying information resources
• Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• AHFI, CFE, Certified Professional Coder
• Strong analytical and research skills
• Strong customer service skills
• Knowledge of CVS/Aetna's policies and procedures

Education

• A Bachelor's degree or equivalent work experience preferred

Pay Range

The typical pay range for this role is:$43,888.00 - $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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS HealthWe anticipate the application window for this opening will close on: 01/03/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.