Senior Investigator, Special Investigations Unit

This is a fully remote position, open to applicants in Alabama, +44 more locations.

📋 Description

• Perform in-depth and intricate investigations of known or suspected healthcare fraud, waste, and abuse.

• Carry out inquiries to avert the payment of questionable or fraudulent claims submitted by insured parties, providers, claimants, and clients.

• Investigate and compile cases for clinical and legal analysis.

• Record all relevant case activities in the case tracking system.

• Generate written case summaries and refer findings to state and federal agencies within legally mandated deadlines.

• Aid in the recovery of funds lost by the company and customers due to fraud, waste, and abuse.

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

• Exhibit advanced knowledge and expertise in interactions with both internal and external stakeholders.

• Provide testimony in court for criminal or civil matters.

• Deliver regular presentations to internal and external clients regarding ongoing investigations.

• Respond promptly and accurately to inquiries and leads from internal and external clients.

• Apply independent judgment and utilize available resources and technology to gather evidence supporting case investigations.

⛳️ Requirements

• 3-5 years of investigative experience in healthcare fraud, waste, and abuse.

• Proficiency in Microsoft Word, Excel, and Outlook.

• Familiarity with open-source database search tools.

• Experience conducting social media and internet research.

• Willingness to travel approximately 10% of the time for business purposes.

• Certification as a Professional Coder (CPC), AHFI, or CFE is preferred.

• Knowledge of CVS/Aetna's policies and procedures is preferred.

• Understanding of self-funded insurance plan operations is preferred.

• Strong communication and customer service skills, with the ability to effectively engage with Aetna's clients preferred.

• A bachelor's degree is preferred or equivalent work experience.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to the base salary range.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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