Bring your heart to CVS Health. Every 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.

Position Summary

• Works 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

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
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• QNXT experience preferred
• Ability to utilize company systems to obtain relevant electronic documentation (ECHS, Alchemy, Claim Central, Medcompass, QNXT, Availity or HRP)
• Strong verbal and written communication skills

Education

• High school diploma or equivalent

Pay Range

The typical pay range for this role is:

$18.50 - $38.82

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/20/2024

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