CVS Health
Overview
Join to apply for the
Senior Investigator (Aetna SIU)
role at
CVS Health .
At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
WEST VIRGINIA RESIDENCY REQUIRED
As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-lines of business, or cases involving multiple perpetrators or intricate healthcare fraud schemes.
Responsibilities
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
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
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the Team Leader as necessary
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
Required Qualifications
WEST VIRGINIA RESIDENCY REQUIRED
3-5 years investigative experience in the area of healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Preferred Qualifications
Previous Medicaid/Medicare investigatory experience
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of Aetna's policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation
Education
Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations)
Anticipated Weekly Hours 40
Time Type Full time
Pay Range The Typical Pay Range For This Role Is $46,988.00 - $91,800.00
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 Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
For more information, visit https://jobs.cvshealth.com/us/en/benefits
Application Window We anticipate the application window for this opening will close on: 10/09/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other, Information Technology, and Management
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at CVS Health by 2x
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Senior Investigator (Aetna SIU)
role at
CVS Health .
At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
WEST VIRGINIA RESIDENCY REQUIRED
As a Senior Investigator you will conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-lines of business, or cases involving multiple perpetrators or intricate healthcare fraud schemes.
Responsibilities
Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in case tracking system
Facilitates feedback with providers related to clinical findings
Initiates proactive data mining to identify aberrant billing patterns
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
Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
Assists Investigators in identifying resources and best course of action on investigations
Serves as back up to the Team Leader as necessary
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
Required Qualifications
WEST VIRGINIA RESIDENCY REQUIRED
3-5 years investigative experience in the area of healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables)
Strong analytical and research skills
Proficient in researching information and identifying information resources
Strong verbal and written communication skills
Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Preferred Qualifications
Previous Medicaid/Medicare investigatory experience
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations for fraud and abuse
Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
Knowledge of Aetna's policies and procedures
Knowledge and understanding of complex clinical issues
Competent with legal theories
Strong communication and customer service skills
Ability to effectively interact with different groups of people at different levels in any situation
Education
Bachelor's degree or equivalent experience (3-5 years of working health care fraud, waste and abuse investigations)
Anticipated Weekly Hours 40
Time Type Full time
Pay Range The Typical Pay Range For This Role Is $46,988.00 - $91,800.00
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 Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
For more information, visit https://jobs.cvshealth.com/us/en/benefits
Application Window We anticipate the application window for this opening will close on: 10/09/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other, Information Technology, and Management
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at CVS Health by 2x
Get notified about new Senior Investigator jobs in Charleston, WV.
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr