Senior Investigator — Healthcare Fraud & Abuse

CVS Health; Baltimore (MD); On-site; USD 47,000 - 102,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Senior Investigator to lead high-level investigations of healthcare fraud and abuse. You will handle sensitive cases, coordinate with clinical and legal teams, and document findings in the case tracking system.

Responsibilities include researching cases for review, identifying fraud patterns, presenting findings to internal and external stakeholders, and supporting proactive controls to reduce losses. Travel up to 10% may be required.

Qualifications

• 3+ years investigative experience in healthcare fraud and abuse matters.
• Working knowledge of CPT, HCPCS, ICD10.
• Advanced skills in Microsoft Excel (pivot tables).

Responsibilities

• Investigates to prevent payment of fraudulent claims submitted to 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, internal and external, in the required timeframe.
• Provides on-the-job training to new Investigators and guidance for less experienced staff.
• Cooperates with law enforcement agencies in investigations.
• Gives presentations to internal/external customers regarding healthcare fraud matters.

Skills

Analytical skills

Communication skills

Documentation

Testimony / presentation

Education

Bachelor's degree or equivalent

Tools

Microsoft Excel

Pivot tables

Job description

CVS Health is seeking a Senior Investigator to lead high-level investigations of healthcare fraud and abuse. You will handle sensitive cases, coordinate with clinical and legal teams, and document findings in the case tracking system.

Responsibilities include researching cases for review, identifying fraud patterns, presenting findings to internal and external stakeholders, and supporting proactive controls to reduce losses. Travel up to 10% may be required.