Senior Investigator, Special Investigations Unit

This is a fully remote position, open to applicants in Alabama, +42 more states.

📋 Description

• Perform in-depth and complex investigations into known or suspected healthcare fraud and abuse.

• Conduct inquiries to avert the payment of fraudulent claims submitted to Medicaid lines of business.

• Research and compile cases for clinical and legal examination.

• Record case activities in the case tracking system.

• Facilitate feedback with providers concerning clinical findings.

• Initiate proactive data mining to detect unusual billing patterns.

• Make internal and external referrals within stipulated timeframes.

• Aid in the recovery of funds lost by the company and customers due to fraudulent activities.

• Provide on-the-job training and mentorship to less experienced Investigators.

• Assist Investigators with resources and recommend best practices.

• Act as a backup to the Team Leader when required.

• Collaborate with federal, state, and local law enforcement on healthcare fraud investigations and prosecutions.

• Offer testimony during civil and criminal court proceedings.

• Present information to both internal and external stakeholders regarding healthcare fraud issues and Aetna's strategies.

• Contribute to the development of fraud-monitoring controls within business units.

⛳️ Requirements

• A minimum of 3 years of investigative experience in healthcare fraud and abuse matters.

• Proficient understanding of medical coding, including CPT, HCPCS, and ICD10.

• Advanced skills in Microsoft Excel, including the use of pivot tables.

• Experience with Microsoft Office.

• Willingness to travel up to 10% of the time (approximately 2–3 times per year, based on business needs).

• A bachelor's degree or equivalent experience (3+ years of working on healthcare fraud, waste, and abuse investigations).

• Prior experience in Medicaid/Medicare investigations is preferred.

• Professional credentials such as CFE or AHFI are preferred.

• Familiarity with Aetna's policies and procedures is preferred.

• Understanding of complex clinical issues is preferred.

• Knowledge of legal theories is preferred.

• Strong analytical and research capabilities.

• Proficient in gathering information and identifying relevant resources.

• Excellent verbal and written communication skills.

• Ability to effectively engage with diverse groups at various organizational levels.

🏝️ Benefits

• Eligibility for CVS Health bonus, commission, or short-term incentive programs in addition to base salary.

• Comprehensive medical coverage.

• Dental insurance.

• Vision insurance.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources promoting physical, emotional, and financial well-being.