Behavioral Health Senior Investigator (BCBA), Special Investigations Unit (Aetna 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 prioritise 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.

The Behavioral Health Senior Investigator is responsible for conducting complex investigations involving Applied Behaviour Analysis (ABA) services and behavioural health providers to identify, detect, and prevent potential fraud, waste, and abuse (FWA). This position utilises clinical and investigative knowledge to analyse provider billing patterns, service utilisation, treatment documentation, and regulatory compliance to identify aberrant activity and support investigative outcomes.

• Conduct behavioural health and ABA-retrospective reviews to identify potential fraud, waste, abuse, and quality of care concerns.
• Analyse clinical documentation, treatment plans, progress notes, billing records, and utilisation patterns for indicators of inappropriate services, overutilisation, unbundling, duplicate billing, or services not supported by clinical documentation.
• Partner with Special Investigations Unit (SIU), Compliance, Legal, Network, and Medical Management teams to support investigations involving ABA providers, behavioural health practitioners, and related service providers.
• Perform clinical reviews and provide subject matter expertise regarding ABA standards of care, medical necessity, and treatment appropriateness.
• Identify emerging fraud schemes, billing anomalies, and provider outlier trends through data analysis and case review activities.
• Prepare concise investigative summaries, clinical findings, and recommendations for internal stakeholders and leadership.
• Participate in provider audits, site visits, record reviews, and corrective action initiatives as needed.
• Support recovery, prepayment review, and provider education efforts when inappropriate billing or service delivery concerns are identified.
• Ensure investigations and reviews comply with applicable regulatory requirements, payer policies, BACB ethical standards, state regulations, and organisational compliance expectations.
• Contribute to the development of fraud prevention strategies, provider education materials, and investigative business rules designed to detect and mitigate fraud, waste, and abuse.

• Current Board-Certified Behaviour Analyst (BCBA) certification.
• Minimum 2-3 years of experience providing ABA services.
• Experience conducting behavioural assessments and treatment planning.
• Ability to Travel for Business purposes.

• Experience working with Autism Spectrum Disorder (ASD) populations.
• Knowledge of healthcare, managed care, or behavioural health systems.
• Experience in interdisciplinary care coordination.
• Experience supporting healthcare fraud, waste, and abuse (FWA) investigations.
• Knowledge of healthcare claims, coding, reimbursement methodologies, and payer audit processes.
• Experience conducting provider record reviews, utilisation analysis, or compliance audits.
• Familiarity with Medicaid, Medicare, commercial health plan operations, and behavioural health reimbursement practices.
• Strong analytical, communication, and organisational skills.

• Master's degree in Applied Behaviour Analysis, Psychology, Education, Special Education, or a related field.

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 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 programme in addition to the base pay range listed above.

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