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Senior Investigator, Special Investigations Unit
CVS HealthCVS Health seeks a Senior Investigator in Special Investigations Unit. Conduct complex investigations into healthcare fraud and abuse to recover lost funds.
Posted 6/25/2026full-timeRemote • Idaho, Illinois, Vermont • 🇺🇸 United StatesSenior💰 $46,988 - $122,400 per yearWebsite
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
health care fraud investigationfraud auditsCPT codingHCPCS codingICD codingclinical issue knowledgeevidence developmentcase trackinglegal proceedings participationpresentation skills
Soft Skills
interpersonal skillsindependent judgementcommunication skillsteam collaborationproblem-solvingconflict resolutionconfidence in testimonyresource identificationadaptabilitycustomer interaction
Tools & Technologies
Microsoft WordMicrosoft ExcelMicrosoft Outlookdatabase search toolsIntranetInternet researchcase tracking systemelectronic documentation systemspresentation softwarefraud monitoring controls
Industry Keywords
healthcare fraudfraud preventionmulti-disciplinary provider groupspayment fraudclaim investigationsfederal law enforcement cooperationstate law enforcement cooperationlocal law enforcement cooperationfraud-related issueshealthcare compliance
About the role
Key responsibilities & impact- Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment
- Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
- Researches and prepares cases for clinical and legal review.
- Documents all appropriate case activity in case tracking system.
- Prepares and presents referrals, both internal and external, in the required timeframe.
- Facilitates the recovery of company lost as a result of fraud matters.
- Assists team in identifying resources and best course of action on investigations.
- 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.
- Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse
Requirements
What you’ll need- 3 years working on health care fraud, waste, and abuse investigatory and audits
- Knowledge of CPT/HCPCS/ICD coding
- Knowledge and understanding of clinical issues
- Experience and proficiency in Microsoft Word, Excel, and Outlook
- Database search tools, and use in the Intranet/Internet to research information
- Ability to effectively interact with different groups of people at different levels in any situation
- Ability to utilize company systems to obtain relevant electronic documentation
- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Benefits
Comp & perks- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- additional resources based on eligibility