Experienced Quality Reviewer – Healthcare Fraud Investigation and Compliance Specialist for Aetna SIU

Introduction to CVS Health and Our Mission

At CVS Health, we are driven by a singular purpose: to bring our heart to every moment of your health. This guiding principle underscores our commitment to delivering human-centric healthcare in a rapidly evolving world. Our brand, with heart at its center, conveys a personal message about the importance of how we deliver our services, not just what we deliver. We strive to empower every colleague to feel valued in their role in transforming our culture and accelerating innovation to make healthcare more personal, convenient, and affordable.

Role Overview: Quality Reviewer for Aetna SIU

We are seeking an experienced and dedicated Quality Reviewer to join our team in the fight against healthcare fraud. As a Quality Reviewer, you will play a critical role in assessing the thoroughness and accuracy of investigations aimed at preventing the payment of fraudulent claims. Your expertise will be instrumental in analyzing and preparing cases for clinical and legal review, ensuring all documentation meets the required standards. This position offers a unique opportunity to utilize your skills and experience in healthcare fraud investigation and compliance to make a meaningful impact.

Key Responsibilities

• Investigation and Analysis: Assess the thoroughness and accuracy of investigations into fraudulent claims, analyzing cases for clinical and legal review to ensure compliance with regulatory standards.
• Case Preparation and Documentation: Prepare and document all relevant case activity in the case tracking system, ensuring thoroughness and accuracy in all documentation.
• Referral Evaluation and Presentation: Evaluate and present referrals, both internal and external, within the required timeframe, providing insights and recommendations based on case reviews.
• Collaboration and Teamwork: Collaborate with the team to identify resources and the best course of action for ongoing investigations, working closely with federal, state, and local law enforcement agencies to ensure compliance and support the prosecution of healthcare fraud and abuse matters.
• Testimony and Presentations: Demonstrate a high level of knowledge and expertise during interactions, providing confident testimony during civil and criminal proceedings, and delivering presentations to internal and external stakeholders regarding healthcare fraud matters and the organization’s approach to combating fraud.
• Input on Controls and Fraud-Related Issues: Provide input on controls for monitoring fraud-related issues within business units, exercising independent judgment and utilizing available resources and technology to develop evidence supporting allegations of fraud and abuse.

Essential Qualifications

• Experience in Healthcare: A minimum of 3 years of experience in healthcare within auditing, compliance, or fraud, waste, and abuse.
• Coding Knowledge: Knowledge of CPT/HCPCS/ICD coding.
• Technical Proficiency: Proficiency in Microsoft Word, Excel, Outlook, database search tools, and internet research.
• Travel and Legal Proceedings: Willingness to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• Certifications: 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 of Medicaid Fraud, Waste, and Abuse review experience.
• Billing and Coding Certifications: Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
• Behavioral Health Knowledge: Knowledge of Behavioral Health policies and procedures is a plus.
• Experience in Behavioral Health Fraud Cases: Experience reviewing Behavioral Health fraud cases.
• Clinical Issues Understanding: Understanding of clinical issues related to healthcare.
• Communication and Customer Service Skills: Strong communication and customer service skills, with the ability to effectively interact with diverse groups of people at various levels in any situation.
• Analytical and Research Skills: Strong analytical and research skills using healthcare data, with proficiency in researching information and identifying relevant resources.

Education

A Bachelor’s degree or three years of experience in healthcare fraud, waste, and abuse investigations and audits.

Compensation and Benefits

The typical pay range for this role is $43,888.00 - $102,081.60. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above. Our comprehensive benefits package includes medical, dental, and vision benefits, a 401(k) retirement savings plan, an Employee Stock Purchase Plan, fully-paid term life insurance, short-term and long-term disability benefits, numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. We also offer Paid Time Off (PTO) or vacation pay, as well as paid holidays throughout the calendar year.

Career Growth Opportunities and Learning Benefits

At CVS Health, we are committed to the growth and development of our colleagues. This role offers opportunities for professional development, continuing education, and career advancement in the field of healthcare fraud investigation and compliance. You will have access to a range of training programs, workshops, and conferences to enhance your skills and knowledge, as well as the opportunity to work with a talented team of professionals who share your passion for combating healthcare fraud.

Work Environment and Company Culture

Our company culture is built on a foundation of respect, empathy, and inclusivity. We value diversity and promote a work environment that is collaborative, supportive, and empowering. As a Quality Reviewer, you will be part of a dynamic team that is dedicated to making a positive impact on the healthcare industry. We offer a remote work arrangement, providing you with the flexibility to work from anywhere, while still being connected to our team and the resources you need to succeed.

Conclusion

If you are a motivated and experienced professional looking for a challenging and rewarding role in healthcare fraud investigation and compliance, we encourage you to apply for this exciting opportunity. As a Quality Reviewer for Aetna SIU, you will have the chance to make a meaningful difference in the fight against healthcare fraud, while developing your skills and advancing your career in a supportive and dynamic environment. Don’t miss out on this opportunity to join our team and start your future with CVS Health. Apply now!