Senior Investigator, Special Investigation Unit (Fully Remote)
CVS Health, Richmond, VA, United States
Position Summary
Conduct investigations to effectively pursue prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.
Communicate with federal, state, and local law enforcement agencies as appropriate in matters pertaining to prosecution of specific healthcare fraud cases.
Investigate to prevent payment of fraudulent claims committed by insurers, providers, claimants, customer members, etc.
Facilitate recovery of company and customer money lost as a result of fraud matters.
Provide input regarding controls for monitoring fraud‑related issues within business units.
Deliver educational programs designed to promote deterrence and detection of fraud and minimize losses to the company.
Maintain open communication with constituents within and external to the company.
Use available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Research and prepare cases for clinical and legal review.
Document all appropriate case activity in tracking system.
Make referrals and deconflictions, both internal and external, in the required timeframe.
Cost‑effectively manage use of outside resources and vendors to perform necessary investigation activities.
Exhibit behaviors outlined in Employee Competencies.
Attend and present at quarterly state meetings.
Required Qualifications
1+ year’s experience working with Medicaid.
Over three years in healthcare field working in fraud, waste and abuse investigations and audits.
Proficiency in researching information and identifying information resources.
Ability to interact with different groups of people at different levels and provide timely assistance.
Experience working in Microsoft Word, Excel, Outlook products.
Experience with database search tools and use of intranet/internet to research information.
Ability to utilize company systems to obtain relevant electronic documentation.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Preferred Qualifications
Knowledge of Virginia Medicaid.
Credits such as a certification from the Association of Certified Fraud Examiners (CFE).
Accreditation from the National Health Care Anti‑Fraud Association (AHFI).
Billing and coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
Knowledge of Aetna's policies and procedures.
Education
Bachelor’s degree and/or an Associate’s degree with three additional years working in health care fraud, waste, and abuse investigations and audits.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The Typical Pay Range for This Role Is:
$46,988.00 - $102,000.00
This 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.
Great Benefits For Great People
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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Conduct investigations to effectively pursue prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.
Communicate with federal, state, and local law enforcement agencies as appropriate in matters pertaining to prosecution of specific healthcare fraud cases.
Investigate to prevent payment of fraudulent claims committed by insurers, providers, claimants, customer members, etc.
Facilitate recovery of company and customer money lost as a result of fraud matters.
Provide input regarding controls for monitoring fraud‑related issues within business units.
Deliver educational programs designed to promote deterrence and detection of fraud and minimize losses to the company.
Maintain open communication with constituents within and external to the company.
Use available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Research and prepare cases for clinical and legal review.
Document all appropriate case activity in tracking system.
Make referrals and deconflictions, both internal and external, in the required timeframe.
Cost‑effectively manage use of outside resources and vendors to perform necessary investigation activities.
Exhibit behaviors outlined in Employee Competencies.
Attend and present at quarterly state meetings.
Required Qualifications
1+ year’s experience working with Medicaid.
Over three years in healthcare field working in fraud, waste and abuse investigations and audits.
Proficiency in researching information and identifying information resources.
Ability to interact with different groups of people at different levels and provide timely assistance.
Experience working in Microsoft Word, Excel, Outlook products.
Experience with database search tools and use of intranet/internet to research information.
Ability to utilize company systems to obtain relevant electronic documentation.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Preferred Qualifications
Knowledge of Virginia Medicaid.
Credits such as a certification from the Association of Certified Fraud Examiners (CFE).
Accreditation from the National Health Care Anti‑Fraud Association (AHFI).
Billing and coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
Knowledge of Aetna's policies and procedures.
Education
Bachelor’s degree and/or an Associate’s degree with three additional years working in health care fraud, waste, and abuse investigations and audits.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The Typical Pay Range for This Role Is:
$46,988.00 - $102,000.00
This 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.
Great Benefits For Great People
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
#J-18808-Ljbffr