SIU Sr Investigator - West Virginia - Work From Home

CVS Health

Charleston West Virginia

United States

Scientific Research
(No Timezone Provided)

Job Description
Must be physically in West Virginia.

You will oversee Corporate activities related to the prevention, investigation and prosecution of health care and disability fraud and to recover lost funds.

Responsible for compliance with state and federal regulations mandating the reporting of Corporate fraud related activities and the preparation of Corporate Anti Fraud Plan

• Conducts more high level, complex investigations of known or suspected acts of healthcare/disability fraud and abuse.Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes

• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer
members, etc

• Researches and prepares cases for clinical and legal review

• Documents all appropriate case activity in case tracking system

• 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
Must be physically in West Virginia.

3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters. Understanding of health plan operations, including contracting, claims processing, encounter data processing, and Medicaid eligibility and enrollment.

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.


Preferred Qualifications
Experience navigating a matrixed organization.

Expertise in the West Virginia Medicaid regulatory environment.

Education
Bachelor's Degree

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.


We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

SIU Sr Investigator - West Virginia - Work From Home

CVS Health

Charleston West Virginia

United States

Scientific Research

(No Timezone Provided)

Job Description
Must be physically in West Virginia.

You will oversee Corporate activities related to the prevention, investigation and prosecution of health care and disability fraud and to recover lost funds.

Responsible for compliance with state and federal regulations mandating the reporting of Corporate fraud related activities and the preparation of Corporate Anti Fraud Plan

• Conducts more high level, complex investigations of known or suspected acts of healthcare/disability fraud and abuse.Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes

• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer
members, etc

• Researches and prepares cases for clinical and legal review

• Documents all appropriate case activity in case tracking system

• 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
Must be physically in West Virginia.

3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters. Understanding of health plan operations, including contracting, claims processing, encounter data processing, and Medicaid eligibility and enrollment.

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.


Preferred Qualifications
Experience navigating a matrixed organization.

Expertise in the West Virginia Medicaid regulatory environment.

Education
Bachelor's Degree

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.


We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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