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.
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), Self-Funded investigations team.
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
Resident of North Carolina
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 - $112,200.00This 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.
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
CVS Health Insights
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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.
