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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 CompetenciesRequired 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 RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain 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, religious belief, or other legally recognized reasons that prevents them from being 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 or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.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 Louisiana Medicaid and/or Aetna's policies and procedures is a plusEducation- A Bachelor's degree, or an Associate's degree with an additional three years working in health care fraud, waste, and abuse investigations and auditsBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.