Senior Investigator, Special Investigations Unit; SIU

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.

• 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.

• 4+ years investigative experience in the area of healthcare fraud, waste and abuse matters.
• Working knowledge of medical coding; CPT, HCPCS, ICD
  10.
• 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).

• 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.

Bachelor's degree or equivalent experience (A bachelor's degree, or an associate's degree with an additional four+ years working on health care fraud, waste, and abuse investigations and audits)

40

Full time

The typical pay range for this role is: $46,988.00 - $ This pay range represents the base hourly rate or base annual full‑time salary for all…