Senior Investigator, Aetna SIU (Must reside in ...

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

As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases, or cases involving multiple perpetrators or intricate healthcare fraud schemes.

• Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
• Researches and prepares cases for clinical and legal review
• Documents all appropriate case activity in case tracking system
• Facilitates feedback with providers related to clinical findings
• Initiates proactive data mining to identify aberrant billing patterns
• Makes referrals, both internal and external, in the required timeframe
• Facilitates the recovery of money lost as a result of fraud matters
• Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.
• Assists Investigators in identifying resources and best course of action on investigations
• Serves as back up to the manager as necessary
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
• Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
• Provides input regarding controls for monitoring fraud related issues within the business units

Required Qualifications

• Must live in the state of Ohio
• 4+ years investigative experience in the area of healthcare fraud, waste and abuse matters.
• Working knowledge of medical coding; CPT, HCPCS, ICD10
• Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables).
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.
• The ability to understand and analyze health care claims and coding
• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Preferred Qualifications

• Previous Medicaid/Medicare investigatory experience
• Previous Behavioral Health experience
• Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse.
• Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
• Knowledge of Aetna's policies and procedures.
• Knowledge and understanding of complex clinical issues.
• Competent with legal theories.
• Strong communication and customer service skills.
• Ability to effectively interact with different groups of people at different levels in any situation.

Education

Bachelor's degree or equivalent experience ( A bachelor's degree, or an associate's degree with an additional four+ years working on health care fraud, waste, and abuse investigations and audits;

• 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.