Job Description
This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am – 5 pm EDT)
Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.
Fundamental Components:
– Conducts investigations of known or suspected acts of healthcare fraud, waste, 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, abusive, or otherwise improperly billed claims submitted by providers, members, and others
– Facilitates the recovery of company and customer monetary losses
– Provides input regarding controls for preventing or 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, waste, and abuse
– Researches and prepares cases for clinical and legal review
– Documents all appropriate case activity in tracking system
– Makes referrals, both internal and external, in the required timeframe
– Exhibits behaviors outlined in Employee Competencies
– Exhibits behaviors outlined in SIU Investigator Competencies
– May include travel to testify in court proceedings or training if necessary
Pay Range
The typical pay range for this role is:
Minimum: 40,560
Maximum: 81,100
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
– Investigative experience, preferably in the area of healthcare fraud, waste and abuse
– Experience in healthcare/medical insurance claims investigation or professional/clinical experience
– Background with law enforcement agencies; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims
– 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 to research information
– Ability to utilize company systems to obtain relevant electronic documentation
Preferred Qualifications
– AHFI, CFE, Certified Professional Coder
– Knowledge of CVS/Aetna’s policies and procedures
Education
– College degree in Criminal Justice or related field
Business Overview
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.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services.
We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
