Senior Investigator, Special Investigations Unit (Aetna SIU)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

• Conducts high level, complex analysis of Dental Providers and Practices to effectively pursue the prevention, investigation and prosecution of Fraud, Waste and Abuse.  
• Collaboration with Dental Network, providing meaningful evidence of Fraud, Waste and Abuse to support corrective action. 
• Routinely handles cases that are sensitive or high profile, those that are national in scope.
• Investigates to prevent payment of fraudulent activities.
• Researches and prepares cases for clinical, legal and leadership review.
• Documents all appropriate case activity in case tracking system.
• Makes referrals, both internal and external, in the required timeframe.
• Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution.
• 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 Dental matters.
• Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units.
• Maintains open communication with constituents within and external to the company.

• 3-5 years of healthcare fraud investigations experience
• Experience with Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research
• Ability to travel for business purposes and legal proceedings
• Proficient in data analysis and research
• Knowledge of Medical Terminology

• Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
• Bilingual in English/Spanish
• Strong verbal and written communication skills.
• Strong customer service skills.
• Knowledge of Aetna's policies and procedures
• Ability to interact with different groups of people at different levels.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Clinical or FWA Dental experience

• Bachelor's degree in Criminal Justice, Biological Science, Law, Healthcare Administration, or Health Information Management or equivalent experience.

The typical pay range for this role is:

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.