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

We are seeking an experienced Senior Healthcare Fraud Investigator to join our Dental/Pharmacy/Broker Investigative Team within Aetna’s Special Investigations Unit. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

REQUIRED QUALIFICATIONS

• 3-5 years investigative experience in the area of healthcare fraud, waste and abuse.
• Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.
• Strong communication and customer service skills and the ability to effectively interact with Aetna’s customers.
• Proficiency in Word, Excel, MS Outlook products, open source database search tools, social media and internet research.
• Ability to Travel for Business purposes.

PREFERRED QUALIFICATIONS

• Certified Professional Coder (CPC), AHFI, CFE
• Bilingual English/Spanish
• Dental Investigative experience
• Pharmacy Investigative experience
• Marketplace Broker Investigative experience
• Medicaid and Medicare experience

EDUCATION

• Bachelor’s degree in Criminal Justice or equivalent experience

• Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse.
• Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured’s, providers, claimants and customers.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in case tracking system.
• Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
• Facilitates the recovery of company and customer money lost as a result of fraud, waste and abuse.
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
• Demonstrates high level of knowledge and expertise during interactions with internal and external partners.
• Provide Trial Testimony in support of Criminal or Civil proceedings.
• Gives presentations to internal and external customers regarding ongoing case investigations.