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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 uni
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
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $102,000.00This 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.