Healthcare Fraud Senior Manager, Special Investigations Unit Lead

6 days ago


Woonsocket, Rhode Island, United States CVS Health Full time
Job Summary

The Special Investigations Unit at CVS Health is seeking a Senior Manager to lead our new ASO investigations team. As a Healthcare Fraud Senior Manager, you will be responsible for overseeing and managing fraud detection, investigation, and prevention efforts to safeguard the organization's resources and reduce healthcare costs.

Key Responsibilities:

• Lead and mentor a team of fraud investigators, analysts, and other staff, providing guidance and support in fraud detection and prevention efforts.
• Establish team goals, monitor performance, and ensure alignment with organizational objectives.

Fraud Detection and Prevention:

• Work closely with analytics team to contribute to the development of fraud detection strategies using data analytics, machine learning, and other advanced techniques to identify patterns of fraudulent behavior.
• Conduct risk assessments to identify vulnerabilities in the organization's processes and implement measures to mitigate these risks. Design and manage proactive fraud prevention programs to minimize exposure to fraudulent activities.

Investigation Management:

• Direct and oversee complex investigations into suspected healthcare fraud, waste, and abuse.
• Ensure timely and accurate reporting of investigation findings and coordinate with legal and compliance teams to take appropriate action.
• Collaborate with law enforcement agencies, regulatory bodies, and external partners during investigations when necessary.
• Prepare comprehensive reports summarizing investigation outcomes, risk assessments, and fraud trends.

Compliance and Regulatory Adherence:

• Ensure all fraud investigation and prevention activities comply with state, federal, and industry regulations.
• Stay informed about changes in laws, regulations, and industry practices related to healthcare fraud.
• Assist in preparing documentation for audits, compliance reviews, and regulatory inquiries.

Requirements:

• Minimum 7+ years of experience in healthcare fraud detection, investigation, or auditing.
• In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.
• Strong leadership and team management ability.
• Excellent communication and presentation skills.
• Ability to work cross-functionally with various teams and external partners.

Preferred Qualifications:

• Minimum 3+ years in a leadership role.
• Relevant certifications (e.g., Certified Fraud Examiner (CFE), accredited healthcare fraud investigator (AHFI)).
• Bachelor's degree preferred in healthcare administration, finance, criminal justice, or related field/specialized training/relevant professional qualification.

What We Offer:

• Competitive pay range: $75,400.00 - $199,144.80.
• Bonus, commission, or short-term incentive program.
• Equity award program.
• Comprehensive benefits package, including medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan.
• Paid Time Off (PTO) or vacation pay.
• Paid holidays throughout the calendar year.
• CVS store discount and discount programs with participating partners.
• Well-being programs, education assistance, and free development courses.

CVS Health is 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.

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