Senior SIU Investigator (Fully Remote)
CVS Pharmacy - Tallahassee, FL
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Job DescriptionThis position can be work from home anywhere in the United States. Must be willing to work EDT schedule. - 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 ofhealthcare fraud and abuse.- Communicates with federal, state, and local lawenforcement agencies as appropriate in matterspertaining to the prosecution of specific healthcare fraudcases.- Investigates to prevent payment of fraudulent claimscommitted by insured's, providers, claimants, customermembers, etc.- Facilitates the recovery of company and customermoney lost as a result of fraud matters.- Provides input regarding controls for monitoring fraudrelated issues within the business units.- Delivers educational programs designed to promotedeterrence and detection of fraud and minimize losses tothe company- Maintains open communication with constituents withinand external to the company.- Uses available resources and technology in developingevidence, supporting allegations of fraud and abuse.- Researches and prepares cases for clinical and legalreview.- Documents all appropriate case activity in trackingsystem.- Makes referrals and deconflictions, both internal and external, in the required timeframe.- Cost effectively manages use of outside resources andvendors to perform activities necessary for investigations.- Exhibits behaviors outlined in Employee Competencies- Attending and presenting at quarterly state meetings.Pay RangeThe typical pay range for this role is:Minimum: 43,700Maximum: 100,000Please 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- Knowledge of Florida Medicaid- 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 identifyinginformation 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 toresearch information.- Ability to utilize company systems to obtain relevantelectronic documentation.- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.Preferred Qualifications- Credentials such as a certification from the Association ofCertified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI). - Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)- Knowledge of Aetna's policies and procedures.Education- Bachelor's degree and/or an Associate's degree with three additional years working in health care fraud, waste, and abuse investigations and audits.Business OverviewBring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 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.
Created: 2024-09-07