Senior Investigator, Special Investigations Unit

CVS Health

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

Posted 10/5/2026full-timeRemote • Oklahoma • United StatesSenior💰 $46,988 - $91,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, including data analysis, medical coding, and collaboration with stakeholders. Proficient in utilizing investigative tools and methodologies to identify and prevent aberrant billing practices.

Highest-signal resume keywords

Healthcare Fraud Investigation ExperienceMedical Coding KnowledgeAdvanced Excel SkillsPower BI ProficiencyCFE or AHFI Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisResearch SkillsClaims Data AnalysisProactive Data MiningInvestigative StrategyRegulatory ComplianceCase PreparationTestifying in ProceedingsDocumentation SkillsPresentation Skills

Soft Skills

Strong Communication SkillsCollaboration SkillsSelf-Starter AttitudeAnalytical AbilityTraining and Guidance

Tools & Technologies

Microsoft OfficeExcelPower BICase-Tracking SystemSIU Tools

Certifications & Qualifications

CFEAHFI

Industry Keywords

MedicaidMedicareHealthcare FraudFraud PreventionClinical IssuesBilling PatternsProgram IntegrityRegulatory RequirementsHealthcare ComplianceFraud Waste and Abuse

About the role

Key responsibilities & impact

Conduct high-level, complex investigations of known or suspected healthcare fraud and abuse
Investigate program-integrity matters to prevent payment of aberrant Medicaid claims
Conduct thorough research on subjects and related entities
Independently initiate proactive data mining using SIU tools to identify aberrant billing patterns and detect schemes early
Analyze claims data to determine aberrancy, patterns, or schemes
Research and prepare cases for clinical and legal review
Collaborate with Medical Directors on clinical issues and medical-record questions
Document case activity and communications in the designated case-tracking system
Communicate clinical findings to providers
Adhere to regulatory requirements
Facilitate case outcomes to recover company and customer monies lost from aberrant billing
Provide training and guidance to new and junior investigators
Assist junior investigators with resources and investigative strategy
Serve as backup to the Team Leader as necessary
Collaborate with federal, state, and local law-enforcement agencies on healthcare-fraud investigations and prosecutions
Testify in civil and criminal proceedings
Prepare and deliver presentations on healthcare-fraud matters and the enterprise FWA approach
Communicate efficiency-gain ideas and provide input on FWA monitoring controls

Requirements

What you’ll need

Must reside in Oklahoma
2-5 years investigative experience in healthcare fraud and abuse matters
Working knowledge of medical coding; CPT, HCPCS, ICD10
Proficient in Microsoft Office
Advanced skills in Excel; pivot tables are a must
Power BI skills
Self-starter who initiates research vital to an investigation
Proficient in researching information and identifying new resources helpful to cases
Ability to travel up to 10%
Medicaid/Medicare investigation experience preferred
Knowledge of applicable Medicaid/Medicare rules and regulations preferred
Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI) credentials preferred
Knowledge and understanding of complex clinical issues preferred
Ability to effectively interact and collaborate with various stakeholders and departments preferred
Strong verbal and written communication skills preferred
Strong analytical ability to view and slice claims data in multiple facets preferred
Bachelor's degree or equivalent experience (5+ years of working health care fraud, waste and abuse investigations)

Benefits

Comp & perks

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