Senior Investigator, Special Investigations Unit

CVS Health

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

Posted 10/22/2026full-timeRemote • United StatesSenior💰 $46,988 - $102,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting complex healthcare fraud investigations, utilizing advanced analytical skills and knowledge of medical coding. Proficient in collaborating with law enforcement and providing training to team members while ensuring compliance with regulatory standards.

Highest-signal resume keywords

Healthcare Fraud InvestigationMedical Coding: CPT, HCPCS, ICD10Advanced Microsoft Excel SkillsCFE or AHFI CredentialsStrong Analytical and Research Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare Fraud InvestigationMedical Coding: CPTMedical Coding: HCPCSMedical Coding: ICD10Advanced Microsoft Excel SkillsCase DocumentationData MiningLegal Theory CompetenceResearch ProficiencyFraud-Monitoring Controls

Soft Skills

Strong Verbal Communication SkillsStrong Written Communication SkillsInterpersonal SkillsTraining and GuidanceCollaboration

Tools & Technologies

Microsoft OfficeCase Tracking System

Certifications & Qualifications

CFEAHFI

Industry Keywords

MedicaidMedicareHealthcare FraudFraud PreventionClinical ReviewLegal ProceedingsBilling PatternsAetna Policies

About the role

Key responsibilities & impact

Conduct high-level, complex investigations of known or suspected healthcare fraud and abuse
Investigate to prevent payment of fraudulent claims submitted to Medicaid lines of business
Research and prepare cases for clinical and legal review
Document case activity in the case tracking system
Facilitate feedback with providers regarding clinical findings
Initiate proactive data mining to identify aberrant billing patterns
Make internal and external referrals within required timeframes
Facilitate recovery of company and customer money lost through fraud matters
Provide on-the-job training and guidance to less experienced Investigators
Assist Investigators with resources and best courses of action
Serve as backup to the Team Leader as necessary
Cooperate with federal, state, and local law enforcement in healthcare fraud investigations and prosecutions
Provide testimony during civil and criminal proceedings
Present to internal and external customers on healthcare fraud matters and Aetna's approach
Provide input on fraud-monitoring controls within business units

Requirements

What you’ll need

3+ years investigative experience in healthcare fraud and abuse matters
Working knowledge of medical coding: CPT, HCPCS, ICD10
Advanced Microsoft Excel skills, including pivot tables
Microsoft Office experience
Ability to travel up to 10% (approximately 2–3 times per year, depending on business needs)
Bachelor's degree or equivalent experience (3+ years of working health care fraud, waste and abuse investigations)
Previous Medicaid/Medicare investigatory experience preferred
Credentials such as CFE or AHFI preferred
Knowledge of Aetna's policies and procedures preferred
Knowledge and understanding of complex clinical issues preferred
Competence with legal theories preferred
Strong analytical and research skills
Proficiency in researching information and identifying information resources
Strong verbal and written communication skills
Ability to effectively interact with different groups of people at different levels

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