Enable job alerts via email!
Analyst, Investigator (Aetna SIU)
CVS Health
United States
Remote
USD 43,000 - 94,000
Full time
Generate a tailored resume in minutes
Land an interview and earn more. Learn more
Job summary
CVS Health is seeking a Fraud Investigator to conduct investigations and ensure compliance with healthcare fraud regulations. The role requires strong analytical skills and a minimum of 3 years in the healthcare field, focusing on fraud prevention and recovery. Join a team dedicated to transforming healthcare with compassion and efficiency.
Benefits
Qualifications
- Over 3 years in healthcare fraud investigations.
- Proficient in research and analytical skills.
- Strong verbal and written communication required.
Responsibilities
- Conduct investigations of healthcare fraud and abuse.
- Communicate with law enforcement agencies.
- Document all case activities in tracking systems.
Skills
Education
Tools
Job description
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
- Conducts investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.
- Conducts investigations of known or suspected acts of healthcare fraud 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 claims committed by insured's, providers, claimants, customer members, etc.
- Facilitates the recovery of company and customer money lost as a result of fraud matters.
- Provides input regarding controls for 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 and abuse.
- Researches and prepares cases for clinical and legal review.
- Documents all appropriate case activity in tracking system.
- Makes referrals and deconflictions, both internal and external, in the required timeframe.
- Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.
Required Qualifications
- Must be located in Maryland.
- Knowledge of Maryland Medicaid - State Of Maryland- Maryland Department of Health (MDH), andt he Code of Maryland Regulations, often referred to as COMAR.
-
- Over 3 years in healthcare field working in fraud, waste and abuse investigations and audits.
- Strong analytical and research skills.
- Proficient in researching information and identifying information resources.
- 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.
- Proficiency in Word, Excel, MS Outlook products,
- Database search tools, and use in the Intranet/Internet to research information.
- Ability to utilize company systems to obtain relevant electronic documentation.
- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Preferred Qualifications
- Credentials such as a certification from the Association of Certified Fraud Examiners (CFE)
- An accreditation from the National Health Care Anti-Fraud Association (AHFI).
- Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA)
- Knowledge of Aetna's policies and procedures
Education
- Bachelor’s degree and/or an Associate’s degree with three additional years working in health care fraud, waste, and abuse investigations and audits.
Anticipated Weekly Hours
40At 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
- Conducts investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.
- Conducts investigations of known or suspected acts of healthcare fraud 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 claims committed by insured's, providers, claimants, customer members, etc.
- Facilitates the recovery of company and customer money lost as a result of fraud matters.
- Provides input regarding controls for 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 and abuse.
- Researches and prepares cases for clinical and legal review.
- Documents all appropriate case activity in tracking system.
- Makes referrals and deconflictions, both internal and external, in the required timeframe.
- Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.
Required Qualifications
- Must be located in Maryland.
- Knowledge of Maryland Medicaid - State Of Maryland- Maryland Department of Health (MDH), andt he Code of Maryland Regulations, often referred to as COMAR.
-
- Over 3 years in healthcare field working in fraud, waste and abuse investigations and audits.
- Strong analytical and research skills.
- Proficient in researching information and identifying information resources.
- 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.
- Proficiency in Word, Excel, MS Outlook products,
- Database search tools, and use in the Intranet/Internet to research information.
- Ability to utilize company systems to obtain relevant electronic documentation.
- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Preferred Qualifications
- Credentials such as a certification from the Association of Certified Fraud Examiners (CFE)
- An accreditation from the National Health Care Anti-Fraud Association (AHFI).
- Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA)
- Knowledge of Aetna's policies and procedures
Education
- Bachelor’s degree and/or an Associate’s degree with three additional years working in health care fraud, waste, and abuse investigations and audits.
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: 07/24/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.
Talentify is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Talentify provides reasonable accommodations to qualified applicants with disabilities, including disabled veterans. Request assistance at accessibility@talentify.io or 407-000-0000.
Federal law requires every new hire to complete Form I-9 and present proof of identity and U.S. work eligibility.
An Automated Employment Decision Tool (AEDT) will score your job-related skills and responses. Bias-audit & data-use details: www.talentify.io/bias-audit-report . NYC applicants may request an alternative process or accommodation at aedt@talentify.io or 407-000-0000.
job faster
Follow us
