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CVS Health Sr. Analyst Specialist Unit Investigator (Must be in Dallas, TX area) in Dallas, Texas

Job Description

  • 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

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 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.

COVID Requirements

CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.

If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.

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), 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.

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