[Hiring] Fraud, Waste & Abuse (FWA) Investigator @CVS Health

Role Description

This individual contributor role supports complex investigations and contributes to organizational compliance with federal and state regulations. The position plays a key role in identifying fraud risks, supporting program integrity efforts, and helping to prevent financial losses related to fraud, waste, and abuse.

• Performs complex investigations related to healthcare fraud, waste, and abuse (FWA), with a focus on compliance with the No Surprises Act (NSA).
• Responsible for analyzing healthcare data, conducting investigations, ensuring regulatory compliance, and supporting program integrity initiatives.

Key Responsibilities

• Directs complex investigations, including data analysis, interviews, and document review, to identify potential fraud, waste, and abuse, including NSA-related activity.
• Conducts investigations into suspected fraud, waste, and abuse associated with the No Surprises Act (NSA), including independent dispute resolutions.
• Investigates dispute outcomes and identifies providers submitting non-NSA claims to CIDRE.
• Prioritizes and manages cases to ensure timely, accurate, and compliant investigations.
• Analyzes healthcare data and claims to identify patterns, trends, and anomalies indicative of fraud.
• Supports risk mitigation efforts and ensures compliance with regulatory requirements, including NSA provisions.
• Ensures investigative reports are accurate, complete, and compliant with legal and regulatory standards.
• Develops and delivers training on fraud, waste, and abuse prevention, including NSA requirements.
• Provides guidance and mentorship to team members during investigations.
• Advises management on fraud trends, regulatory changes, and best practices.
• Collaborates with internal partners and external stakeholders to support investigations.
• Partners with law enforcement, as appropriate, to support investigation and prosecution efforts.
• Maintains stakeholder communication and provides input on fraud risk controls.

Qualifications

• 5+ years of experience in healthcare fraud, waste, and abuse investigations or related program integrity functions.
• Experience analyzing healthcare claims data.
• Knowledge of healthcare regulatory requirements.
• Strong analytical, investigative, and problem-solving skills.
• Ability to manage multiple priorities and meet established timelines.

Preferred Qualifications

• Experience with the No Surprises Act (NSA).
• Familiarity with CIDRE.
• Experience working with regulatory agencies or law enforcement.
• Certifications such as Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI).
• Advanced knowledge of healthcare claims processing and billing practices.

Education

• Bachelor’s degree or equivalent combination of education and experience.

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $66,330.00 - $145,860.00. 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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.

Application Information

We anticipate the application window for this opening will close on: 07/27/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.