Senior Investigator, Special Investigations Unit (Aetna SIU)

CVS Health; Sioux Falls (SD); Presencial; USD 47.000 - 102.000; Jornada completa

Descripción de la vacante

CVS Health in the United States seeks a Senior Investigator to lead high-level investigations into healthcare fraud and abuse, including complex cases with multiple perpetrators. You will handle Medicaid-related fraud matters,prepare cases for clinical and legal review, and document all activity.

You will train junior investigators, coordinate with providers, and collaborate with law enforcement as needed. Strong knowledge of CPT/HCPCS/ICD10, advanced Excel, and ability to travel up to 10% are

Formación

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

Responsabilidades

• 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
• Cooperates with federal, state, and local law enforcement agencies in investigations

Conocimientos

Healthcare fraud investigations

Medical coding knowledge CPT/HCPCS/ICD

Excel pivot tables

Travel up to 10%

Educación

Bachelor's degree or equivalent experience

Herramientas

Microsoft Office

Descripción del empleo

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 complex cases involving 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 company and customer 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 Team Leader 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

• 3+ years investigative experience in the area of healthcare fraud and abuse matters.
• Working knowledge of medical coding; CPT, HCPCS, ICD10
• Experience with Microsoft Office with advanced skills in Excel (must know how to do pivot tables).
• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Preferred Qualifications

• Previous Medicaid/Medicare investigatory 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.
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.

Education:

• Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $46,988.00 - $102,000.00This 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.

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.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments .

Application Closing Date

We anticipate the application window for this opening will close on: 12/04/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.