OhioRISE SIU Investigator (Must Reside in Ohio)

Job DescriptionAs part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.The Special Investigative Unit (SIU) Investigator is a fully telework-based position. Must reside in Ohio. The SIU Investigator conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.- Routinely handles cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.- 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.- Makes referrals, both internal and external, in the required timeframe.- Facilitates the recovery of company and customer money 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.Required Qualifications- Minimum one (1) year working on health care fraud, waste, and abuse investigations and audits required.- Knowledge of CPT/HCPCS/ICD coding- Knowledge and understanding of clinical issues.- Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.- Strong communication and customer service skills. - Ability to effectively interact with different groups of people at different levels in any situation.- Strong analytical and research skills.- Proficient in researching information and identifying information resources.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Knowledge of Ohio Medicaid/Medicare, Aetna's policies and procedures.- Credentials such as a certification from the Association ofCertified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid/Medicare Fraud, Waste and Abuse investigatory experience.- Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)- Experience in behavioral health investigations- Experience in insurance claims investigation or professional/clinical experience, background with law enforcement agenciesEducation- A Bachelor's degree or an Associate's degree with an additional two years (4 years total) working on health care fraud, waste, and abuse investigations and audits required.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-01