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CVS Health

Bringing our heart to every moment of your health.

Senior Investigator, Special Investigations Unit

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

Location

Florida

Posted

1 day ago

Salary

$47.0K - $102K / year

Seniority

Senior

Bachelor Degree3 yrs expEnglish

Job Description

Senior Investigator, Special Investigations Unit

CVS Health

• Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment • Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc. • Researches and prepares cases for clinical and legal review. • Documents all appropriate case activity in case tracking system. • Prepares and presents referrals, both internal and external, in the required timeframe. • Facilitates the recovery of company lost as a result of fraud matters. • Assists team in identifying resources and best course of action on investigations. • 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. • Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse

Job Requirements

  • Must reside in Florida.
  • 3 years working on health care fraud, waste, and abuse investigatory and audits required.
  • Knowledge of CPT/HCPCS/ICD coding
  • Knowledge and understanding of clinical issues.
  • Experience and proficiency in Microsoft Word, Excel, and Outlook, Database search tools, and use in the Intranet/Internet to research information.
  • Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
  • Ability to travel to provider offices within the state of Florida on a monthly basis

Benefits

  • medical, dental, and vision coverage
  • paid time off
  • retirement savings options
  • wellness programs
  • other resources, based on eligibility

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