Investigator, Special Investigations Unit (Meritain Health)

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.

As an independently owned subsidiary of Aetna and CVS Health, Meritain Health is a leading third‑party administrator of self‑insured commercial health plans. The SIU Investigator will support Meritain Health’s Network Cost Management team, specifically the Special Investigations Unit (SIU).

The SIU Investigator will conduct 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.

The SIU Investigator

• Must be flexible to work EDT hours (8:00 am - 5 pm EDT).
• Conduct investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, in order to recover lost funds, as well as to comply with state regulations mandating fraud plans and practices.
• Conduct investigations of known or suspected acts of healthcare fraud and abuse.
• Communicate with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases.
• Investigate to prevent payment of fraudulent claims committed by insured’s, providers, claimants, customer members, etc.
• Facilitate the recovery of company and customer money lost as a result of fraud matters.
• Provide input regarding controls for monitoring fraud related issues within the business units.
• Deliver educational programs designed to promote deterrence and detection of fraud and minimize losses to the company.
• Maintain open communication with constituents internal and external to the company.
• Use available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Research and prepare cases for clinical and legal review.
• Document all appropriate case activity in tracking system.
• Make referrals and deconflictions, both internal and external, in the required timeframe.
• Cost‑effectively manage use of outside resources and vendors to perform activities necessary for investigations.

Required Qualifications

• 3+ years of experience working in fraud, waste and abuse investigations and audits.
• 3+ years of experience in healthcare/medical insurance claims investigation or professional/clinical experience.
• Demonstrated proficiency in Microsoft Office Suite (including Excel, specifically with pivot tables), database search tools, and use of the Intranet/Internet to research information.

Preferred Qualifications

• Strong analytical and research skills.
• Strong verbal and written communication skills.
• Strong customer service skills.
• Previous experience as a senior investigator.
• Previous experience utilizing QuickBase.
• Proficient in researching information and identifying information resources.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
• Ability to interact with different groups of people at different levels and aid on a timely basis.
• Previous experience working with a Third‑Party Administrator (TPA) and/or Self‑Funded Plans in an investigative capacity.
• AHFI (Accredited Health Care Fraud Investigator), CFE (Certified Fraud Examiner), and/or CPC (Certified Professional Coder).
• Knowledge of CVS/Aetna/Meritain Health’s policies and procedures.

Education

• Bachelor’s Degree or equivalent work experience (high school diploma or GED + 4 years of relevant work experience).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $46,988.00 - $122,400.00. 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.

Great Benefits for Great People

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.