Job Description

Position Summary We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), Self‑Funded investigations team. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA). Work Location This position can be worked from home anywhere in the United States. Key Responsibilities Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse. Conduct investigations to prevent payment of suspect or fraudulent claims submitted by insureds, providers, claimants, and customers. Research and prepare cases for clinical and legal review. Document all appropriate case activity in case tracking system. Prepare written case summaries and make referrals to State and Federal Agencies within required timeframes. Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse. Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud. Demonstrate high level of knowledge and expertise during interactions with internal and external partners. Provide trial testimony in support of criminal or civil proceedings. Give frequent presentations to internal and external customers regarding ongoing case investigations. Respond quickly and accurately to questions and leads from internal and external customers. Exercise independent judgment and use available resources and technology to develop evidence in support of case investigations. Required Qualifications 3‑5 years investigative experience in the area of healthcare fraud, waste and abuse. Experience with Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research. Ability to travel approximately 10% of the time for business purposes. Preferred Qualifications Certified Professional Coder (CPC), AHFI, CFE. Knowledge of CVS/Aetna's policies and procedures. Understanding of self‑funded insurance plan operations. Strong communication and customer service skills and the ability to effectively interact with Aetna's customers. Resident of North Carolina. Education Bachelor's degree preferred or equivalent work experience. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 - $112,200.00. This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above. Benefits This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. EEO Statement Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr

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