Senior Investigator, Special Investigations Unit

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

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

• Examine program-integrity concerns to prevent the payment of irregular Medicaid claims.

• Conduct comprehensive research on individuals and related entities.

• Proactively initiate data mining using SIU tools to identify unusual billing patterns and detect schemes at an early stage.

• Analyze claims data to identify anomalies, patterns, or schemes.

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

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

• Record case activities and communications within the designated case-tracking system.

• Relay clinical findings to healthcare providers.

• Comply with regulatory standards.

• Facilitate case resolutions to recover funds lost by the company and customers due to irregular billing.

• Offer training and mentorship to new and junior investigators.

• Support junior investigators with resources and investigative strategies.

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

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

• Provide testimony in civil and criminal court proceedings.

• Prepare and deliver presentations on matters related to healthcare fraud and the enterprise's fraud, waste, and abuse (FWA) approach.

• Share ideas for improving efficiency and contribute insights on FWA monitoring controls.

⛳️ Requirements

• Must be a resident of Oklahoma.

• 2-5 years of investigative experience in healthcare fraud and abuse.

• Familiarity with medical coding systems, including CPT, HCPCS, and ICD10.

• Proficient in Microsoft Office suite.

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

• Experience with Power BI.

• Self-motivated individual who takes initiative in conducting essential research for investigations.

• Skilled in sourcing information and identifying new resources beneficial to cases.

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

• Preferred experience in Medicaid and Medicare investigations.

• Preferred knowledge of relevant Medicaid and Medicare regulations.

• Preferred certifications from the Association of Certified Fraud Examiners (CFE) or the National Health Care Anti-Fraud Association (AHFI).

• Preferred understanding of complex clinical issues.

• Preferred ability to effectively communicate and collaborate with various stakeholders and departments.

• Preferred strong verbal and written communication abilities.

• Preferred strong analytical skills to evaluate and dissect claims data from multiple perspectives.

• Bachelor’s degree or equivalent experience (5+ years in healthcare fraud, waste, and abuse investigations).

🏝️ Benefits

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial wellness.