Special Investigations Unit Senior Investigator
CVS Health, Boston, MA, United States
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, including complex cases involving multiple perpetrators or intricate healthcare fraud schemes.
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
Makes referrals, both internal and external, in the required timeframe
Facilitates the recovery of company and customer money lost as a result of fraud matters
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the Team Leader as necessary
Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
Gives presentations to internal and external customers regarding healthcare fraud matters and CVS Health’s approach to fighting fraud
Provides input regarding controls for monitoring fraud related issues within the business units
Required Qualifications
3+ years investigative experience in the area of healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
Ability to travel up to 10% (approximately 2-3x per year, depending on business needs)
Preferred Qualifications
Previous Medicaid/Medicare investigatory experience
Exercises independent judgment and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of CVS Health’s policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation
Education
Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations)
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The Typical Pay Range For This Role Is $46,988.00 - $112,200.00
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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Benefits
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.
We anticipate the application window for this opening will close on: 04/27/2026
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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Position Summary
As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, including complex cases involving multiple perpetrators or intricate healthcare fraud schemes.
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
Makes referrals, both internal and external, in the required timeframe
Facilitates the recovery of company and customer money lost as a result of fraud matters
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the Team Leader as necessary
Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
Gives presentations to internal and external customers regarding healthcare fraud matters and CVS Health’s approach to fighting fraud
Provides input regarding controls for monitoring fraud related issues within the business units
Required Qualifications
3+ years investigative experience in the area of healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
Ability to travel up to 10% (approximately 2-3x per year, depending on business needs)
Preferred Qualifications
Previous Medicaid/Medicare investigatory experience
Exercises independent judgment and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of CVS Health’s policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation
Education
Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations)
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The Typical Pay Range For This Role Is $46,988.00 - $112,200.00
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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Benefits
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.
We anticipate the application window for this opening will close on: 04/27/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
#J-18808-Ljbffr