SIU Investigator

CVS Health; Hartford (CT); Remote; USD 43,000 - 113,000; Full time

Job summary

CVS Health is seeking an Investigator to join its Network Cost Management team, focusing on the prevention and investigation of healthcare fraud and abuse. This role involves conducting investigations, collaborating with law enforcement, and ensuring compliance with state regulations. The position allows for remote work across the United States and requires flexibility to work EDT hours.

Benefits

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings and counseling programs

Tuition assistance

Qualifications

• 3+ years’ experience in fraud investigations and audits.
• Experience in healthcare/medical insurance claims investigation.
• Ability to travel for legal proceedings.

Responsibilities

• Conduct investigations to prevent healthcare fraud and abuse.
• Communicate with law enforcement regarding fraud cases.
• Document case activity in tracking systems.

Skills

Analytical skills

Research skills

Verbal communication

Written communication

Customer service

Education

Bachelor's Degree or relevant work experience

Tools

MS Outlook

Database search tools

Job description

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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

As an independently owned subsidiary of Aetna and CVS Health, Meritain Health is a leading third-party administrator of self-insured commercial health plans. The Investigator will support Meritain Health’s Network Cost Management team, specifically the Special Investigations Unit (SIU).

The SIU Investigator will conduct 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

This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT)

• 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

• 3+ years’ experience working in fraud, waste and abuse investigations and audits.
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience.
• Strong analytical and research skills.
• Strong verbal and written communication skills
• Strong customer service skills.
• Proficient in researching information and identifying information resources.
• Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
• 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.
• Ability to interact with different groups of people at different levels and aid on a timely basis.
  
  

Preferred Qualifications

• Experience with Third Party Administrator (TPA)/Self-Funded Plans including investigations.
• AHFI, CFE, Certified Professional Coder (CPC)
• Knowledge of CVS/Aetna/Meritain Health’s policies and procedures
  
  

Education

• Bachelor's Degree or relevant work experience
  
  

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The Typical Pay Range For This Role Is

$43,888.00 - $112,200.00

This 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: 05/26/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other, Information Technology, and Management

• Industries

  Hospitals and Health Care

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