Siu Senior Investigator

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT)

Conducts high level, complex analysis of claims and correspondence to effectively pursue the prevention, investigation and prosecution of health care fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans.

Fundamental Components:

• Conducts more high level, complex investigations of known or suspected acts of healthcare fraud and abuse.
• Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.
• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, members, etc.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in case tracking system.
• 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.
• Communicates and cooperates with federal, state, and local law enforcement agencies to assist 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 Aetna's approach to fighting fraud.
• Provides input regarding controls for monitoring fraud related issues within the business units.
• Maintains open communication with constituents within and external to the company.
• Exhibits behaviors outlined in Employee Competencies.
• Exhibits behaviors outlined in SIU Investigator Competencies.
• May include travel to testify in court proceedings or training if necessary.

Required Qualifications

• 3-5 years Investigative experience in the area of healthcare fraud, waste and abuse.
• Experience with Individual and Family Plans (IFP) including investigations.
• 2+ years experience with Behavioral Health investigations and coding.
• Strong knowledge of medical terminology/CPT/HCPCS coding.
• Advanced skills with Microsoft Excel.
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience.
• Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims.
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
• Strong verbal and written communication skills.
• Strong customer service skills.
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• AHFI, CFE, Certified Professional Coder
• Bilingual in English/Spanish
• Knowledge of CVS/Aetna's policies and procedures

Education

• Bachelor's degree in Criminal Justice or related field or equivalent experience.

Pay Range

The typical pay range for this role is:

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.
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.