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CVS Health

Bringing our heart to every moment of your health.

Senior Investigator, Special Investigations Unit

GeneralGeneralFull TimeRemoteSeniorTeam 10,001+Since 1963H1B No SponsorCompany SiteLinkedIn

Location

Massachusetts

Posted

7 hours ago

Salary

$47.0K - $112.2K / year

Seniority

Senior

Bachelor Degree5 yrs expExperience acceptedEnglish

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

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