Senior Investigator, Aetna SIU (Must reside in Ohio) at CVS Health

, Ohio, United States -

Full Time

Start Date

Immediate

Expiry Date

03 Jul, 26

Salary

91800.0

Posted On

04 Apr, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Healthcare fraud investigation, Medical coding, CPT, HCPCS, ICD10, Microsoft Office, Excel, Pivot tables, Data mining, Analytical skills, Research skills, Verbal communication, Written communication, Clinical review, Legal review, Case documentation

Industry

Hospitals and Health Care

Description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary 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, 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 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 manager 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 Must live in the state of Ohio 4+ years investigative experience in the area of healthcare fraud, waste 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. The ability to understand and analyze health care claims and coding Ability to travel up to 10% (approx. 2-3x per year, depending on business needs) Preferred Qualifications Previous Medicaid/Medicare investigatory experience Previous Behavioral Health 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 ( A bachelor's degree, or an associate's degree with an additional four+ years working on health care fraud, waste, and abuse investigations and audits; Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 - $91,800.00 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: 05/01/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.

Responsibilities

Conduct complex investigations into healthcare fraud, waste, and abuse to prevent fraudulent payments within Medicaid lines of business. Document case activity, facilitate provider feedback, and collaborate with law enforcement agencies during civil and criminal proceedings.