Position Details

Type Not Specified

Experience senior

Exp. Years 3 years

Education Bachelor's degree, or Associate's degree, with 3 years healthcare fraud investigations and audits

Category Healthcare & Medical

About this role

Investigator within CVS Health SIU conducting complex healthcare fraud investigations, preparing cases for clinical and legal review, and collaborating with law enforcement.

Key Responsibilities

Handle complex cases involving behavioral health or multi-disciplinary provider groups
Investigate to prevent fraudulent claims
Prepare cases for clinical and legal review
Document case activity in tracking system
Present referrals and cooperate with law enforcement

Technical Overview

Strong knowledge of coding (CPT/HCPCS/ICD) and case management tools; proficient in Microsoft Word/Excel/Outlook; capable of presenting findings in legal settings and traveling as needed.

Ideal Candidate

The ideal candidate is a senior healthcare fraud investigator with 3+ years of healthcare fraud, waste, and abuse experience, strong CPT/HCPCS/ICD coding knowledge, and proficiency with Word/Excel. They should be comfortable testifying in legal proceedings and traveling as needed.

Must-Have Skills

3 years working on health care fraudwasteand abuse investigatory and audits requiredKnowledge of CPT/HCPCS/ICD codingExperience and proficiency in Microsoft WordExceland OutlookAbility to travel and participate in legal proceedings

Nice-to-Have Skills

CFEAHFICPCCCSBehavioral Health fraud experience

Required Skills

CPT/HCPCS/ICD codingMicrosoft WordExcelOutlookcase tracking systemhealthcare fraud knowledgelitigation preparation

Hard Skills

CPTHCPCSICDclinical knowledgeMicrosoft WordExcelOutlookcase tracking systemdepositionstestimony

Soft Skills

communicationinterpersonalresearchanalytical thinkingpresentation

Certifications

Preferred

Certified Fraud Examiner (CFE)AHFICPCCCS

Industry & Role

Industry Healthcare & Medical

Job Function Investigate and pursue healthcare fraud and abuse cases, prepare evidence for review, and support legal proceedings.

Role Subtype Senior Investigator - SIU

Keywords for Your Resume

senior investigatorspecial investigations unitaetna siuhealthcare fraudfraud investigationsCPTHCPCSICDcodingcase tracking systemdepositionstestimonylaw enforcementclinical reviewregulatory compliancebachelor's degreeCFEAHFICPCCCSeducationExcelOutlook

Deal Breakers

Less than 3 years healthcare fraud experience, No CPT/HCPCS/ICD coding knowledge, Inability to travel or participate in legal proceedings

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