# Senior Investigator

**Company**: CVS Health
**Experience**: senior
**Job type**: full-time
**Salary**: $46,988.00 - $102,000.00
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/Work-At-Home-Florida/Senior-Investigator--Special-Investigations-Unit--Aetna-SIU-_R1079201?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/job/senior-investigator-dd5511ae-110/

## Description

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

As a Senior Investigator, you will conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse.

Responsibilities:

- Investigate to prevent payment of fraudulent claims submitted to the Medicaid lines of business

- Research and prepare cases for clinical and legal review

- Document all appropriate 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, both internal and external, in the required timeframe

- Facilitate the recovery of company and customer money lost as a result of fraud matters

- Provide on-the-job training to new Investigators and guidance for less experienced or skilled Investigators

- Assist Investigators in identifying resources and best course of action on investigations

- Serve as backup to the Team Leader as necessary

- Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters

- Demonstrate high level of knowledge and expertise during interactions and act confidently when providing testimony during civil and criminal proceedings

- Give presentations to internal and external customers regarding healthcare fraud matters and approach to fighting fraud

- Provide input regarding controls for monitoring fraud-related issues within business units

Required Qualifications:

- 3+ years investigative experience in healthcare fraud and abuse matters

- Working knowledge of medical coding; CPT, HCPCS, ICD10

- Experience with Microsoft Office, advanced skills in Excel (pivot tables)

- Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Preferred Qualifications:

- Previous Medicaid/Medicare investigatory experience

- Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or accreditation from the National Health Care Anti-Fraud Association (AHFI)

- Knowledge of complex clinical issues

- Strong communication and customer service skills

- 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 healthcare fraud, waste and abuse investigations)

Anticipated Weekly Hours: 40 Time Type: Full-time Pay Range: $46,988.00 - $102,000.00

Benefits:

- Medical, dental, and vision coverage

- Paid time off

- Retirement savings options

- Wellness programs

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## Skills

### Required
- medical coding
- CPT
- HCPCS
- ICD10
- Microsoft Office
- Excel

### Nice to have
- Medicaid/Medicare investigatory experience
- Association of Certified Fraud Examiners (CFE)
- National Health Care Anti-Fraud Association (AHFI)
- complex clinical issues
- communication
- analytical skills

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