Job Description

Senior Investigator

At CVS Health, we are 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 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 national in scope, complex cases, or cases involving multiple perpetrators or intricate healthcare fraud schemes.

• 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 money lost as a result of fraud matters
• Provide on the job training to new Investigators and provide guidance for less experienced or skilled Investigators
• Assist Investigators in identifying resources and best course of action on investigations
• Serve as back up to the manager 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 acts confidently when providing testimony during civil and criminal proceedings
• Give presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
• Provide input regarding controls for monitoring fraud related issues within the business units

Required Qualifications

Must live in the state of Ohio. 4+ years investigative experience in the area of healthcare fraud, waste and abuse matters. Working knowledge of medical coding; CPT, HCPCS, ICD10. Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables). Strong analytical and research skills. Proficient in researching information and identifying information resources. Strong verbal and written communication skills. The ability to understand and analyze health care claims and coding. Ability to travel up to 10% (approx. 2-3x per year, depending on business needs).

Preferred Qualifications

Previous Medicaid/Medicare investigatory experience. Previous Behavioral Health 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.

Education

Bachelor's degree or equivalent experience (A bachelor's degree, or an associate's degree with an additional four+ years working on health care fraud, waste, and abuse investigations and audits)

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $46,988.00 - $91,800.00

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

We anticipate the application window for this opening will close on: 12/18/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Job Tags

Similar Jobs