Senior Investigator, Special Investigations Unit

Senior Healthcare Fraud InvestigatorAt 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. This position can be work from home anywhere in the United States.Position Summary We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), dedicated to a specific self-funded plan sponsor. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).Key ResponsibilitiesConduct 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.Research and prepare cases for clinical and legal review.Document 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.Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse.Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.Demonstrate high level of knowledge and expertise during interactions with internal and external partners.Provide trial testimony in support of criminal or civil proceedings.Give frequent presentations to internal and external customers regarding ongoing case investigations.Respond quickly and accurately to questions and leads from internal and external customers.Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.Required Qualifications3-5 years investigative experience in the area of healthcare fraud, waste and abuse.Experience in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research.Ability to travel approximately 10% of time for business purposes.Preferred QualificationsCertified Professional Coder (CPC), AHFI, CFEKnowledge of CVS/Aetna's policies and proceduresUnderstanding of self-funded insurance plan operationsStrong communication and customer service skills and the ability to effectively interact with Aetna's customers.EducationBachelor's degree preferred or equivalent work experience.Anticipated Weekly Hours 40Time Type Full timePay Range The typical pay range for this role is: $46,988.00 - $122,400.00Great 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.We anticipate the application window for this opening will close on: 01/03/2026 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.