• Conducts 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.
• Conducts investigations of known or suspected acts of

healthcare fraud and abuse*

• Communicates with federal, state, and local law

enforcement agencies as appropriate in matters
pertaining to the prosecution of specific healthcare fraud
cases*

• Investigates to prevent payment of fraudulent claims

committed by insured's, providers, claimants, customer
members, etc.

• Facilitates the recovery of company and customer

money lost as a result of fraud matters*

• Provides input regarding controls for monitoring fraud

related issues within the business units*

• Delivers educational programs designed to promote

deterrence and detection of fraud and minimize losses to
the company

• Maintains open communication with constituents within

and external to the company.

• Uses available resources and technology in developing

evidence, supporting allegations of fraud and abuse.

• Researches and prepares cases for clinical and legal

review.

• Documents all appropriate case activity in tracking

system

• Makes referrals and deconflictions, both internal and external, in the required timeframe
• Cost effectively manages use of outside resources and

vendors to perform activities necessary for investigations

• Exhibits behaviors outlined in Employee Competencies

Pay Range
The typical pay range for this role is:
Minimum: 43,700
Maximum: 100,000

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

• Over 3 years in healthcare field working in fraud, waste and abuse investigations and audits.
• Strong analytical and research skills.
• Proficient in researching information and identifying

information resources.

• Strong verbal and written communication skills.
• Strong customer service skills.
• Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
• Proficiency in Word, Excel, MS Outlook products,

Database search tools, and use in the Intranet/Internet to
research information.

• Ability to utilize company systems to obtain relevant

electronic documentation.

Preferred Qualifications

• Credentials such as a certification from the Association of

Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid/Medicare Fraud, Waste and Abuse investigatory experience.

• Billing and Coding certifications such as CPC (AAPC)

and/or CCS (AHIMA)

• Knowledge of Texas Medicaid and/or Aetna's policies and procedures is a plus

Education

• A Bachelor’s degree, or an Associate’s degree with an additional three years working in health care fraud, waste, and abuse investigations and audits

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.