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At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

WEST VIRGINIA RESIDENCY REQUIRED

As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-lines of business, or cases involving multiple perpetrators or intricate healthcare fraud schemes.

Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business

Researches and prepares cases for clinical and legal review

Documents all appropriate case activity in case tracking system

Facilitates feedback with providers related to clinical findings

Initiates proactive data mining to identify aberrant billing patterns

Makes referrals, both internal and external, in the required timeframe

Facilitates the recovery of company and customer money lost as a result of fraud matters

Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.

Assists Investigators in identifying resources and best course of action on investigations

Serves as back up to the Team Leader as necessary

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

Required Qualifications

WEST VIRGINIA RESIDENCY REQUIRED

3-5 years investigative experience in the area of healthcare fraud and abuse matters.

Working knowledge of medical coding; CPT, HCPCS, ICD10

Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables).

Strong analytical and research skills.

Proficient in researching information and identifying information resources.

Strong verbal and written communication skills.

Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Preferred Qualifications

Previous Medicaid / Medicare investigatory experience

Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse.

Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)

Knowledge of Aetna's policies and procedures.

Knowledge and understanding of complex clinical issues.

Competent with legal theories.

Strong communication and customer service skills.

Ability to effectively interact with different groups of people at different levels in any situation.

Education :

• Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is :

$46,988.00 - $102,000.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include :

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .

No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

We anticipate the application window for this opening will close on : 12 / 19 / 2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. 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.