Description

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 health care one person, one family and one community at a time.

Position Summary

• This position is a remote position but West Virginia residency is required.
• Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.

What you will do:

• Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business
• Researches and prepares cases for clinical and legal review
• Documents all appropriate case activity in case tracking system
• Facilitates feedback with providers related to clinical findings
• Initiates proactive data mining to identify aberrant billing patterns
• Makes referrals, both internal and external, in the required timeframe
• Facilitates the recovery of company and customer money lost as a result of fraud matters
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
• Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
• Provides input regarding controls for monitoring fraud related issues within the business units
• Interacts with different groups of people at different levels and provide assistance on a timely basis
• Utilizes company systems to obtain relevant electronic documentation.

Required Qualifications

• Reside in West Virginia
• 3+ years of Investigative experience in the area of healthcare fraud, waste and abuse
• Strong knowledge of medical terminology/CPT/HCPCS coding.
• Advanced skills with Microsoft Excel
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience
• Strong analytical and research skills
• Proficient in researching information and identifying information resources
• Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• AHFI, CFE, Certified Professional Coder
• Knowledge of CVS/Aetna's policies and procedures
• Strong verbal and written communication skills
• Strong customer service skills

Education

• Bachelor's degree or equivalent work experience

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$43,888.00 - $76,500.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. 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 people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 06/01/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.