Senior Investigator, Special Investigations Unit

CVS Health

CVS 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

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

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