Job Description

Senior Healthcare Fraud Investigator

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.

This position can be work from home anywhere in the United States.

Position Summary

We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), dedicated to a specific self-funded plan sponsor. In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

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 insured's, 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 the timeframes required by Law.
• 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.
• Exercises independent judgment and uses 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 in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research.
• Ability to travel approximately 10% of 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.

Education

• Bachelor's degree preferred or equivalent work experience.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range $46,988.00 - $122,400.00

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.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 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.

We anticipate the application window for this opening will close on: 01/03/2026

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