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.
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 Responsibilities
- Conduct 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 Qualifications
- 3-5 years investigative experience in the area of healthcare fraud, waste and abuse.
- Experience in 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 Qualifications
- Certified Professional Coder (CPC), AHFI, CFE
- Knowledge of CVS/Aetna's policies and procedures
- Understanding of self-funded insurance plan operations
- Strong communication and customer service skills and the ability to effectively interact with Aetna's customers.
Education
- Bachelor'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 - $122,400.00This 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: 01/03/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Top Skills
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.
