[Hiring] Senior Investigator @CVS Health

Role Description

The SIU Senior Investigator conducts complex investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.

• Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment.
• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in case tracking system.
• Prepares and presents referrals, both internal and external, in the required timeframe.
• Facilitates the recovery of company lost as a result of fraud matters.
• Assists team in identifying resources and best course of action on investigations.
• 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 Aetna's approach to fighting fraud.
• Provides input regarding controls for monitoring fraud related issues within the business units.
• Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.

Qualifications

• 3 years working on health care fraud, waste, and abuse investigatory and audits required.
• Knowledge of CPT/HCPCS/ICD coding.
• Knowledge and understanding of clinical issues.
• Experience and proficiency in Microsoft Word, Excel, and Outlook, Database search tools, and use in the Intranet/Internet to research information.
• Ability to effectively interact with different groups of people at different levels in any situation.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Requirements

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
• Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
• Knowledge of Behavioral Health policies and procedures.
• Experience working Behavioral Health fraud cases.
• Strong analytical and research skills using health care data.
• Strong communication and customer service skills.
• Proficient in researching information and identifying information resources.

Education

• Bachelor's degree, or an Associate's degree, with an additional three years (3 years total) working on health care fraud, waste, and abuse investigations and audits required.

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.