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
The Investigator role will conduct high level, investigations of known or suspected acts of healthcare fraud and abuse. This position will routinely handle high profile or highly sensitive matters involving cases with multiple subjects, or intricate healthcare fraud schemes.
- Conduct state specific investigations for Louisiana for program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
- Conduct thorough research on subject(s) and related entities
- Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
- Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
- Research and prepare cases for both clinical and legal review
- Collaborate with Medical Directors on clinical issues and medical record questions
- Accurately documents all case activity and communications in designated case tracking system
- Communicate clinical findings to provider
- Adherence to all regulatory requirements
- Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
- Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
- Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
- Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
- Strong communication skills, both written and oral, are necessary for the development and implementation of professional presentations for internal and external stakeholders regarding healthcare fraud matters and Enterprise approach to FWA
- Communicate ideas on efficiency gains; provides input regarding controls for monitoring FWA among the business segments
Required Qualifications
- State residency required; must reside in Louisiana
- 3+ years investigative experience in healthcare fraud and abuse matters
- Working knowledge of medical coding; CPT, HCPCS, ICD10
- Proficient in Microsoft Office with advanced skills in Excel (pivot tables are a must, etc.)
- Strong analytical ability to view and slice claims data in multiple facets
- Self-starter: initiates research that will be vital to an investigation
- Proficient in researching information and identifying new resources helpful to all cases
- Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
- Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Preferred Qualifications
- Medicaid/Medicare investigation experience; knowledge of applicable rules and regulations
- Exercises independent judgement; uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
- Credentials: Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI)
- Knowledge of Aetna's policies and procedures/State and Federal requirements (internal applicants)
- Knowledge and understanding of complex clinical issues
- Competent with legal theories of FWA
- Customer-Focused. Ability to effectively interact and collaborate with various stakeholders and departments to drive solution
- Strong communication and customer service skills
Education
- Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations)
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$43,888.00 - $76,500.00This 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.
Skills Required
- 3+ years investigative experience in healthcare fraud and abuse matters
- Working knowledge of medical coding
- Proficient in Microsoft Office with advanced skills in Excel
- Strong analytical ability to view and slice claims data
- Strong verbal and written communication skills
- Ability to travel up to 10%
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
