Bringing our heart to every moment of your health.
Senior Investigator, Special Investigations Unit
Location
Massachusetts
Posted
7 hours ago
Salary
$47.0K - $112.2K / year
Seniority
Senior
Job Description
Senior Investigator, Special Investigations Unit
CVS Health
• Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse • Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment • Conduct thorough research on subject(s) and related entities • Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection • Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme • Research and prepare cases for both clinical and legal review • Collaborate with Medical Directors on clinical issues and medical record questions • Accurately documents all case activity and communications in designated case tracking system • Communicate clinical findings to provider • Adherent to all regulatory requirements • Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing • Provide training and guidance to new and junior investigators • Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy • Serve as back up to the Team Leader as necessary • Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues • Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings • Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
Job Requirements
- 5+ years investigative experience in healthcare fraud and abuse matters
- Working knowledge of medical coding; CPT, HCPCS, ICD10
- Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables.
- Strong analytical ability to view and slice claims data in multiple facets
- Self-starter: initiates research that will be vital to an investigation
- Proficient in researching information and identifying new resources helpful to all cases
- Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
- Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Benefits
- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
Related Guides
Related Categories
Related Job Pages
More General Jobs
• Use effective listening and communication skills to support patients via phone and other support channels • Provide patient and/or caregiver support to address patient questions and concerns utilizing approved talking points • Build trust-based patient relationships based on empathy • Engage each patient to overcome barriers to adherence • Document and maintain records of interactions via a CRM platform • Utilize motivational interviewing and cognitive behavioral therapy techniques • Participate in quality monitoring process to ensure high-quality support • Protect confidential patient health information in accordance with HIPAA Standards
Title Examiner
Proliant Settlement SystemsOur turnkey title agency ownership program is transforming the title insurance industry. www.proliantsms.com
• Examine land title records of routine to some complexity in accordance with company, underwriter and local examining procedures to determine the status of title. • Abstracts and analyzes deeds, deeds of trust/mortgages, easements, judgments, tax assessments, mineral reservations and other applicable instruments. • Research title resources and other public records. • Compiles searched data and issues a commitment based on status of title. • Provide effective underwriting solutions in order to complete a transaction. • Guide customer and/or escrow officer through the closing process. • Search deed and judgement records using various county software and websites. • Check bankruptcies and Patriot Act blacklist website on property owners. • Ability to locate, to compile accurately and to interpret information affecting status of title to real property; to make arithmetic computations; and to draw out legal descriptions.
Title Processor
Proliant Settlement SystemsOur turnkey title agency ownership program is transforming the title insurance industry. www.proliantsms.com
• Manage and process escrow transactions from initiation through closing, ensuring all required documents and funds are accurately handled • Review and verify escrow instructions, purchase agreements, and other transaction documents to ensure compliance with legal and contractual requirements • Coordinate with clients, lenders, real estate agents, and other stakeholders to gather necessary information and documentation for each transaction • Prepare and review escrow documents, including settlement statements, closing disclosures, and other related paperwork • Monitor and track transaction progress, ensuring that all deadlines are met and that any issues are addressed promptly • Disburse escrow funds according to the terms of the contract and ensure accurate recording of all transactions • Conduct final reviews of closing documents to verify accuracy and completeness before distribution • Address and resolve any discrepancies or issues related to escrow transactions, working closely with title officers and other internal teams as needed • Maintain accurate and organized records of all escrow transactions, including documentation and correspondence
• Review claims in utilization review queues for medical necessity and authorization status; determine appropriate processing based on coding and plan language. • Support the daily operations of the Utilization Review department by assisting senior UR team members with case review activities. • Conduct outreach calls and collect data using established scripts, tools, and protocols, while maintaining productivity and service standards. • Process correspondence and faxes in accordance with timeliness standards; escalate to clinical team members when appropriate. • Perform clerical and administrative tasks, including scanning, document retrieval, and urgent claims processing support. • Communicate clearly, professionally, and courteously with internal and external stakeholders to resolve issues. • Provide written direction to other team members (nurses, claims auditors) to support accurate claims processing. • Maintain current knowledge of Standard Operating Procedures, member benefits, rights, and responsibilities. • Ensure compliance with BCBS Association standards and company policies. • Complete other related duties and projects as assigned.



