Senior Healthcare Fraud Investigator

CVS Health; Phoenix (AZ); On-site; USD 47,000 - 102,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Bonus/incentive program

Job summary

CVS Health is seeking a Senior Investigator to conduct high‑level investigations of healthcare fraud and abuse. You will handle complex cases, including Medicaid fraud, and prepare cases for clinical and legal review while documenting all activity in the tracking system.

The role requires 3+ years in healthcare fraud investigations, strong Excel skills (pivot tables), and the ability to travel up to 10%. You will contribute to preventing fraudulent claims and may provide training and guidance to

Qualifications

• 3+ years investigative experience in healthcare fraud and abuse.
• Working knowledge of medical coding: CPT, HCPCS, ICD10.
• Experience with Microsoft Office with advanced Excel (pivot tables).
• Ability to travel up to 10% (2–3x per year).

Responsibilities

• Conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse.
• Investigate to prevent payment of fraudulent claims submitted to Medicaid lines of business.
• Research and prepare cases for clinical and legal review.
• Document all case activity in case tracking system.
• Facilitate feedback with providers related to clinical findings.
• Initiate proactive data mining to identify aberrant billing patterns.
• Make referrals internally and externally within required timeframes.
• Assist in recovering company and customer money lost due to fraud.

Skills

Healthcare fraud investigation

Advanced Excel

Data analysis

Travel readiness

Education

Bachelor's degree

Tools

Excel Pivot Tables

Job description

CVS Health is seeking a Senior Investigator to conduct high‑level investigations of healthcare fraud and abuse. You will handle complex cases, including Medicaid fraud, and prepare cases for clinical and legal review while documenting all activity in the tracking system.

The role requires 3+ years in healthcare fraud investigations, strong Excel skills (pivot tables), and the ability to travel up to 10%. You will contribute to preventing fraudulent claims and may provide training and guidance to