Senior Investigator, Special Investigations Unit (Aetna SIU)

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. The SIU Senior 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...