[Hiring] Senior Investigator @CVS Health

Role Description

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, those that are national in scope, complex cases, or 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 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 manager 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 Aetna's approach to fighting fraud
• Provides input regarding controls for monitoring fraud related issues within the business unit

Qualifications

• 4+ years investigative experience in the area of healthcare fraud, waste and abuse matters
• Working knowledge of medical coding; CPT, HCPCS, ICD10
• Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables)
• The ability to understand and analyze health care claims and coding
• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Requirements

• Ohio residency
• Previous Medicaid/Medicare investigatory experience
• Previous Behavioral Health experience
• Exercises independent judgement 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 an accreditation from the National Health Care Anti-Fraud Association (AHFI)
• Knowledge of Aetna'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
• Strong analytical and research skills
• Proficient in researching information and identifying information resources
• Strong verbal and written communication skills

Benefits

• Comprehensive medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility