SIU Investigator (Fully Remote)

Job DescriptionThis position can be work from anywhere in the United States but must be willing to work EST schedule. Conducts investigations of known or suspected acts of healthcare/disability fraud and abuse Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc. Facilitates the recovery of company and customer money lost as a result of fraud matters Provides input regarding controls for monitoring fraud related issues within the business units Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company Maintains open communication with constituents within and external to the company Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse Researches and prepares cases for clinical and legal review Documents all appropriate case activity in tracking system Makes referrals, both internal and external, in the required timeframe Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations Exhibits behaviors outlined in Employee Competenciesrecovery checks by tracking and forwarding to appropriate area within the company for handling Assists training programs with regard to fraud detection of processors, customer services representatives, plan sponsors, Marketing, Network, etc. Reviews pre-specified claims for potential fraudulent activity and returns them to the claim operation sites for proper adjudication Utilizes Medical Directors and other Aetna personnel to clarify medical necessity and billing appropriateness Handles telephone and written inquiries from provider, members, plan sponsors, law enforcement agencies, etc. Responds to all requests for reconsiderations or appeals Tracks/reports of inventory; reporting of savings/recovery resultsPay RangeThe typical pay range for this role is:Minimum: 40,560Maximum: 81,100Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications Experience in insurance claims investigation or professional/clinical experience, background with law enforcement agencies; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims. Investigative experience, preferably in the area of healthcare/disability fraud and abuse. Strong analytical and research skills. Proficient in researching information and identifying information resources. Strong verbal and written communication skills. Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis. Provide Trial Testimony in support of Criminal or Civil proceedings. Ability to Travel for Business purposes.Preferred Qualifications Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information. Ability to utilize company systems to obtain relevant electronic documentation. Knowledge of Aetna's policies and procedures. CFE, AFHI, CPC or other relevant certification.Education Bachelor's degree in Criminal Justice or Related field. May substitute relevant work experience in field of investigations or healthcare.Business OverviewBring your heart to CVS Health Every 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. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Created: 2025-11-15