Senior Investigator, Special Investigations Unit (Aetna SIU)
Not Disclosed•Full-TimeOn-site
location_onWisconsin Department of Children And Familes, 201, East Washington Avenue, James Madison Park, Madison, Dane County, Wisconsin, 53703, United States
About CVS Health
We're building a world of health around every individual, shaping a more connected, convenient, and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable, and prioritize safety and quality in everything we do. Join us and be part of something bigger—helping to simplify healthcare one person, one family, and one community at a time.
Our teams reflect the customers, patients, members, and communities we serve. We are committed to fostering a workplace where every colleague feels valued and that they belong. Our people fuel our future, and we take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
About the Role
The SIU Senior Investigator is a pivotal role within our Special Investigations Unit, dedicated to conducting complex investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse. This position exists to recover lost funds, ensure compliance with state regulations mandating fraud plans, and protect the integrity of our healthcare systems.
In this role, you will routinely handle complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment. You will act as a key resource for the team, identifying best courses of action and exercising independent judgment to develop evidence and support allegations of fraud and abuse. Your work will involve researching and preparing cases for clinical and legal review, documenting all case activity, and facilitating the recovery of company funds lost to fraud matters.
You will serve as a confident voice for the organization, cooperating with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud. This includes demonstrating high-level expertise during interactions and providing testimony during civil and criminal proceedings. Additionally, you will give presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud, while providing input on controls for monitoring fraud-related issues within business units.
Hiring Process
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. The application window for this opening will close on 06/04/2026.
Equal Opportunity
CVS Health is an equal opportunity/affirmative action employer, committed to diversity in the workplace. We consider qualified applicants regardless of background, including Disability/Protected Veteran status.
Work location
Work model: On-site
Wisconsin Department of Children And Familes, 201, East Washington Avenue, James Madison Park, Madison, Dane County, Wisconsin, 53703, United States
Madison, Wisconsin
Key Responsibilities
- check_circleConduct complex investigations into healthcare fraud and abuse involving behavioral health or multi-disciplinary providers
- check_circleFacilitate the recovery of company funds lost due to fraud matters
- check_circleProvide testimony during civil and criminal proceedings regarding healthcare fraud matters
- check_circleResearch and prepare cases for clinical and legal review to prevent fraudulent claim payments
- check_circleCooperate with federal, state, and local law enforcement agencies in fraud investigations and prosecutions
- check_circleDocument all case activities in the case tracking system and prepare referrals within required timeframes
- check_circleDevelop evidence and support fraud allegations using independent judgment and available technology
- check_circleDeliver presentations to internal and external customers on fraud prevention and Aetna's anti-fraud approach
Requirements
- verified3 years working on health care fraud, waste, and abuse investigatory and audits required
- verifiedKnowledge of CPT/HCPCS/ICD coding
- verifiedKnowledge and understanding of clinical issues
- verifiedExperience and proficiency in Microsoft Word, Excel, and Outlook
- verifiedAbility to travel and participate in legal proceedings
- verifiedBachelor's degree, or an Associate's degree, with an additional three years (3 years total) working on health care fraud, waste, and abuse investigations and audits required
Nice to Have
Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience. Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA). Knowledge of Behavioral Health policies and procedures. Experience working Behavioral Health fraud cases. Strong analytical and research skills using health care data. Strong communication and customer service skills. Proficient in researching information and identifying information resources.
Benefits & Perks
check_circleMedical, dental, and vision coveragecheck_circlePaid time offcheck_circleRetirement savings optionscheck_circleWellness programs
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Skills, education and keywords
Skills: Microsoft Word, Excel, Outlook, CPT, HCPCS, Icd Coding, Cfe, Ahfi, CPC, CCS.
Education: Bachelor's degree required; Associate's degree with 3 years experience required.
Frequently asked questions about Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health
What does a Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health do?expand_more
In this Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health role, you will conduct complex investigations into healthcare fraud and abuse involving behavioral health or multi-disciplinary providers; facilitate the recovery of company funds lost due to fraud matters; provide testimony during civil and criminal proceedings regarding healthcare fraud matters; and research and prepare cases for clinical and legal review to prevent fraudulent claim payments.
What are the requirements for this Senior Investigator, Special Investigations Unit (Aetna SIU) role?expand_more
CVS Health is looking for candidates who meet the following requirements: 3 years working on health care fraud, waste, and abuse investigatory and audits required; Knowledge of CPT/HCPCS/ICD coding; Knowledge and understanding of clinical issues; Experience and proficiency in Microsoft Word, Excel, and Outlook; Ability to travel and participate in legal proceedings; and Bachelor's degree, or an Associate's degree, with an additional three years (3 years total) working on health care fraud, waste, and abuse investigations and audits required.
Where is the Senior Investigator, Special Investigations Unit (Aetna SIU) role at CVS Health located?expand_more
Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health is based in Wisconsin Department of Children And Familes, 201, East Washington Avenue, James Madison Park, Madison, Dane County, Wisconsin, 53703, United States. This is a on-site role.
Is this Senior Investigator, Special Investigations Unit (Aetna SIU) job remote, hybrid, or on-site?expand_more
CVS Health has listed this Senior Investigator, Special Investigations Unit (Aetna SIU) role as on-site.
How much experience is required for this Senior Investigator, Special Investigations Unit (Aetna SIU) role?expand_more
Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health typically requires 3+ years of relevant experience at the senior level.
What skills do you need for the Senior Investigator, Special Investigations Unit (Aetna SIU) role at CVS Health?expand_more
Key skills for Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health include Microsoft Word; Excel; Outlook; CPT; HCPCS; Icd Coding; Cfe; and Ahfi.
What education is required for Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health?expand_more
Educational requirements for this role: Bachelor's degree required; and Associate's degree with 3 years experience required.
What category does the Senior Investigator, Special Investigations Unit (Aetna SIU) role belong to?expand_more
Senior Investigator, Special Investigations Unit (Aetna SIU) at CVS Health is part of the healthcare & nursing job category on Recrutus.