Job Title

Job DescriptionThis position can be Work From Home anywhere in the United. Under the direction of the Special Investigations Leadership to prevent, detect and investigate known or suspected acts of fraud, and acts of a criminal nature that involve Aetna Medicaid Providers/Members fraud for the purpose of protecting the employees, assets and resources of the Company. Review pre-specified claims for potentially fraudulent activity and return those claims to the claim operations team for proper adjudication. Responsible for initial intake of medical records and coordination of the record review. Assists SIU Investigators on complex and sensitive investigations. Communicates with Medical Directors and other Aetna personnel to clarify review determinations and billing appropriateness. Completes projects timely and within state timelines requirements.Pay RangeThe typical pay range for this role is:Minimum: 18.50Maximum: 33.65Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications 2+ years of claims processing or prior medical claim analyst experience. Demonstrates the ability to handle multiple assignments competently, accurately and efficiently Delivers excellent customer service to colleagues and external partners (health plans, state regulators, law enforcement, etc.). Strong analytical and research skills, proficiency in researching information and identifying resources. Proficient in Microsoft Excel Strong verbal and written communication skillsAbility to travel and participate in legal proceedings, arbitrations, depositions, etc.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 Ability to utilize company systems to obtain relevant electronic documentation (ECHS, Alchemy, Claim Central, IOP) QNXT experience preferredEducation High school diploma or equivalentBusiness 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.