CVS Health Manager, Special Investigation in Dallas, Texas
This position can be in any Aetna office or Work From Home anywhere in the United States. - Leads a team of investigators and analysts 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 reporting; Medicaid experience is preferred. - Leads a team in the planning and execution of investigations of acts of healthcare fraud and abuse by both members and providers. - Provides direction and counsel on the handling of cases and facilitates issue resolution. - Assists in identifying resources and best course of action to take in a timely and effective manner. - Conducts case reviews and provides feedback to investigators on completeness and quality of the investigation. - Conducts team member evaluations and provides performance feedback to staff on an ongoing basis. - Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs. - Assesses training needs and works with SIU Director on development plans for team members. - Develops and maintains close working relationships with federal, state, and local law enforcement agencies in the investigation and prosecution of acts of healthcare fraud and abuse. - Participates in state meetings. - Ensures compliance with contractual requirements. - Coordinates and collaborates with compliance and senior leadership. - Contributes to the development and delivery of educational awareness and training programs that meet or exceed those required by state mandates. - Participates in federal and state audits.
- Minimum of two years managing healthcare fraud, waste and abuse investigations and audits. Medicaid/Medicare experience a plus.- Strong verbal and written communication skills.- Ability to interact with different groups of people at different levels and provide assistance on a timely basis.- Proficient in researching information and identifying information resources.- Experience working with state and law enforcement partners.
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.
- Credentials such as a certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)- Billing and Coding certifications such as CPC (AAPC)- Knowledge of Aetna's policies and procedures
- A Bachelor’s degree, or an Associate’s degree with an additional two years of managing health care fraud, waste, and abuse investigations and audits.
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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