Senior Investigator, Special Investigations Unit

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

📋 Description

• Conduct thorough and sophisticated investigations into healthcare fraud and abuse.

• Manage high-profile or sensitive cases, including matters of national importance and complex fraud schemes involving multiple lines and subjects.

• Investigate program-integrity issues related to unusual Medicaid claims.

• Conduct research on subjects and associated entities.

• Independently execute proactive data mining using SIU tools to uncover irregular billing patterns and schemes.

• Analyze claims data to detect anomalies, patterns, and schemes.

• Research and prepare cases for both clinical and legal examination.

• Work collaboratively with Medical Directors on clinical issues and inquiries regarding medical records.

• Document all case activities and communications in the specified tracking system.

• Share clinical findings with providers.

• Comply with all regulatory requirements.

• Assist in recovering funds for the company and its customers lost due to irregular billing.

• Train and mentor new and junior investigators.

• Support junior investigators with resources and investigative strategies.

• Act as Team Leader backup when necessary.

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

• Present knowledge and findings related to healthcare fraud to both internal and external stakeholders.

• Provide testimony in civil and criminal court cases.

• Develop professional presentations on healthcare fraud and enterprise FWA initiatives.

• Suggest improvements for efficiency and contribute to FWA monitoring controls.

⛳️ Requirements

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

• Proficient understanding of medical coding: CPT, HCPCS, ICD10.

• Skilled in Microsoft Office applications.

• Advanced capabilities in Excel; proficiency with pivot tables is essential.

• Experience with Power BI.

• Strong analytical skills to evaluate claims data from various perspectives.

• Ability to independently initiate critical investigative research.

• Skilled in locating information and identifying resources beneficial to cases.

• Willingness to travel up to 10% of the time.

• Bachelor’s degree or equivalent experience required.

• Equivalent experience includes 5 or more years of working on investigations related to healthcare fraud, waste, and abuse.

• Preferred: 5+ years of investigative experience specifically in healthcare fraud and abuse matters.

• Preferred experience in Medicaid/Medicare investigations along with knowledge of relevant rules and regulations.

• Preferred credentials include CFE or AHFI.

• Preferred understanding of complex clinical issues.

• Ability to exercise independent judgment and utilize resources and technology to gather evidence supporting allegations of fraud and abuse.

• Strong verbal and written communication abilities.

• Customer-oriented approach to interact and collaborate effectively with stakeholders and departments.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Eligibility for CVS Health bonuses, commissions, or short-term incentive programs.