At 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.
As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT)
Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.
Fundamental Components:
- Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse
- Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
- Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others
- Facilitates the recovery of company and customer monetary losses
- Provides input regarding controls for preventing or monitoring fraud related issues within the business units
- Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
- Maintains open communication with constituents within and external to the company
- Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, and abuse
- Researches and prepares cases for clinical and legal review
- Documents all appropriate case activity in tracking system
- Makes referrals, both internal and external, in the required timeframe
- Exhibits behaviors outlined in Employee Competencies
- Exhibits behaviors outlined in SIU Investigator Competencies
- May include travel to testify in court proceedings or training if necessary
Required Qualifications
- 1-3 years of Investigative experience in the area of healthcare fraud, waste and abuse
- Strong knowledge of medical terminology/CPT/HCPCS coding.
- Advanced skills with Microsoft Excel
- Experience in healthcare/medical insurance claims investigation or professional/clinical experience
- Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims
- Strong analytical and research skills
- Proficient in researching information and identifying information resources
- Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
- Strong verbal and written communication skills
- Strong customer service skills
- Ability to interact with different groups of people at different levels and provide assistance on a timely basis
- Ability to utilize company systems to obtain relevant electronic documentation
Preferred Qualifications
AHFI, CFE, Certified Professional Coder
Knowledge of CVS/Aetna's policies and procedures
Education
College degree in Criminal Justice or related field
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$43,888.00 - $93,574.00This 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 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: 06/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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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.
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