Senior Investigator, Special Investigations Unit (SIU) at CVS Health in Boise, Idaho, United States Job Description Bring 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. Kentucky Resident is preferred The SIU Investigator conducts complex 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. What you will do - Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment - 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. - Prepares and presents referrals, both internal and external, in the required timeframe. - Facilitates the recovery of company 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 + 3 years working on health care fraud, waste, and abuse investigatory and audits required. + Knowledge of CPT/HCPCS/ICD coding + Knowledge and un To view full details and how to apply, please login or create a Job Seeker account
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