Senior Investigator (Aetna SIU)

Overview

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At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

WEST VIRGINIA RESIDENCY REQUIRED

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 involving multi-lines of business, or cases involving multiple perpetrators or intricate healthcare fraud schemes.

Responsibilities

• 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 company and customer 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 Team Leader 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 units

Required Qualifications

Preferred Qualifications

Education

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The Typical Pay Range For This Role Is $46,988.00 - $91,800.00

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

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

Application Window

We anticipate the application window for this opening will close on : 10 / 09 / 2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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