Senior Investigator, Special Investigations Unit

CVS Health

Senior Investigator in healthcare fraud and abuse for CVS Health. Conducting complex investigations and collaborating with law enforcement agencies on fraud issues.

Posted 7/14/2026full-timeRemote • Massachusetts • 🇺🇸 United StatesSenior💰 $46,988 - $112,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive investigative experience in healthcare fraud and abuse, with strong analytical skills to assess claims data and identify aberrant billing patterns. Proficient in medical coding and adept at collaborating with various stakeholders to facilitate case outcomes and ensure compliance with regulatory requirements.

Highest-signal resume keywords

Healthcare Fraud InvestigationMedical Coding KnowledgeData Analysis SkillsMicrosoft Excel ProficiencyStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Investigative ExperienceData MiningClaims AnalysisMedical CodingCPTHCPCSICD10Case DocumentationWitness TestimonyRegulatory Compliance

Soft Skills

Analytical AbilitySelf-StarterVerbal CommunicationWritten CommunicationCollaboration

Tools & Technologies

SIU ToolsMicrosoft OfficeCase Tracking System

Industry Keywords

Healthcare FraudProgram IntegrityAberrant ClaimsFWA KnowledgeLaw Enforcement Collaboration

About the role

Key responsibilities & impact

conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
Conduct thorough research on subject(s) and related entities
Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
Research and prepare cases for both clinical and legal review
Collaborate with Medical Directors on clinical issues and medical record questions
Accurately documents all case activity and communications in designated case tracking system
Communicate clinical findings to provider
Adherent to all regulatory requirements
Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
Provide training and guidance to new and junior investigators
Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy
Serve as back up to the Team Leader as necessary
Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
Communicate ideas on efficiency gains; provides input regarding controls for monitoring FWA among the business segments

Requirements

What you’ll need

5+ years investigative experience in healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables
Strong analytical ability to view and slice claims data in multiple facets
Self-starter: initiates research that will be vital to an investigation
Proficient in researching information and identifying new resources helpful to all cases
Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs