Senior Investigator, Special Investigations Unit

CVS Health

. Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse .

Posted 11/12/2026full-timeRemote • United StatesSenior💰 $46,988 - $112,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting complex investigations of healthcare fraud, waste, and abuse, with strong capabilities in case documentation, legal compliance, and effective communication with stakeholders. Proficient in utilizing investigative tools and technologies to support case development and recovery efforts.

Highest-signal resume keywords

Healthcare Fraud InvestigationCase DocumentationMicrosoft Office SuiteCertified Professional Coder (CPC)Open Source Database Search Tools

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare Fraud InvestigationCase DocumentationOpen Source Database Search ToolsSocial Media ResearchEvidence Development

Soft Skills

Strong Communication SkillsCustomer Service SkillsIndependent Judgment

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft Outlook

Certifications & Qualifications

Certified Professional Coder (CPC)AHFICFE

Industry Keywords

Healthcare FraudWaste and AbuseSelf-Funded Insurance Plan OperationsLegal ComplianceCase Tracking System

Tech Stack

Tools & technologies

Open Source

About the role

Key responsibilities & impact

Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse
Conduct investigations to prevent payment of suspect or fraudulent claims submitted by insureds, providers, claimants, and customers
Research and prepare cases for clinical and legal review
Document all appropriate case activity in the case tracking system
Prepare written case summaries and make referrals to state and federal agencies within legally required timeframes
Facilitate recovery of company and customer money lost as a result of fraud, waste and abuse
Cooperate with federal, state, and local law enforcement agencies in healthcare fraud investigations and prosecutions
Demonstrate high-level knowledge and expertise in interactions with internal and external partners
Provide trial testimony for criminal or civil proceedings
Give frequent presentations to internal and external customers regarding ongoing investigations
Respond quickly and accurately to questions and leads from internal and external customers
Exercise independent judgment and use available resources and technology to develop evidence supporting case investigations

Requirements

What you’ll need

3-5 years investigative experience in the area of healthcare fraud, waste and abuse
Experience in Microsoft Word, Excel, and Outlook products
Experience with open source database search tools
Experience with social media and internet research
Ability to travel approximately 10% of time for business purposes
Certified Professional Coder (CPC), AHFI, CFE preferred
Knowledge of CVS/Aetna's policies and procedures preferred
Understanding of self-funded insurance plan operations preferred
Strong communication and customer service skills and the ability to effectively interact with Aetna's customers preferred
Bachelor's degree preferred or equivalent work experience

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to the base pay range
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being