Special Investigations Unit - Investigator

Job DescriptionIn this role, you will be responsible for conducting investigations of known or suspected acts of healthcare/disability fraud and abuse, communicating with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases, as well as investigates to prevent payment of fraudulent claims committed by insureds, providers, claimants, customer members, etc.You will facilitate the recovery of company and customer money lost as a result of fraud matters and provide input regarding controls for monitoring fraud-related issues within the business units You will be delivering educational programs designed to promote deterrence and detection of fraud and minimize losses to the company and maintaining open communication with constituents within and external to the company.You will be able to use available resources and technology in developing evidence, supporting allegations of fraud and abuse to Research and prepare cases for clinical and legal review and document for appropriate case activity in the tracking system You will make referrals both internal and external, in the required timeframe, cost effectively manage the use of outside resources, and vendors to perform activities necessary for investigations.Pay RangeThe typical pay range for this role is:Minimum: 40,560Maximum: 83,400Please 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-1+ years of healthcare/insurance investigation experiencePreferred QualificationsKnowledge of Aetna's policies and procedures.Ability to utilize company systems to obtain relevant electronic documentation.Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis. Strong verbal and written communication skills. Strong analytical and research skills. Proficient in researching information and identifying information resources. Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.EducationBachelors degree or equivalent work experienceBusiness 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: 2025-10-04