SIU Regional Investigator

CVS Health

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Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose : Bringing our heart to every moment of your health.

This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

• Conducts 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.
• Conducts investigations of known or suspected acts of healthcare fraud and abuse.
• Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases.
• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc.
• Facilitates the recovery of company and customer money lost as a result of fraud matters.
• Provides input regarding controls for monitoring fraud related issues within the business units.
• Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
• Maintains open communication with constituents within and external to the company.
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in tracking system.
• Makes referrals and deconflictions, both internal and external, in the required timeframe.
• Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.

Required Qualifications

• This position can be work from home anywhere in the United States. Must be willing to work EDT schedule.
• Knowledge of The Commonwealth of Pennsylvania Department of Human Services, and surrounding states.
• Over 3 years in healthcare field working in fraud, waste and abuse investigations and audits.
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.
• Strong customer service skills.
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
• Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet / Internet toresearch information.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE)
• An accreditation from the National Health Care Anti-Fraud Association (AHFI).
• Billing and Coding certifications such as CPC (AAPC) and / or CCS (AHIMA)
• Knowledge of Aetna's policies and procedures

Education

Bachelor's degree and / or an Associate's degree with three additional years working in health care fraud, waste, and abuse investigations

and audits.

Pay Range

The typical pay range for this role is :

$40,600.00 - $89,300.00

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ('PTO') or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com / benefits

We anticipate the application window for this opening will close on : 06 / 10 / 2024