Bringing our heart to every moment of your health.
Senior Investigator, Special Investigations Unit
Location
Florida
Posted
1 day ago
Salary
$47.0K - $102K / year
Seniority
Senior
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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