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Position Summary

Aetna is seeking an experienced and highly analytical Senior Manager in the Special Investigations Unit to lead the oversight and implementation of Special Investigations Unit Fraud Lead program requirements and compliance. This Independent contributor requires deep expertise in medical, dental and pharmacy claims operations, as well as a thorough understanding of coding practices, emerging fraud trends and the development of analytics to combat fraudulent activities.  The candidate will be responsible for monitoring analytical fraud leads and identify possible training need opportunities for any identified issues. 

Key Responsibilities

• Develop and implement strategic initiatives to enhance the effectiveness of fraud leads and prevention efforts within the SIU.
  Monitor and evaluate the performance of SIU investigative staff and productivity metrics to ensure operational rigor.
• Implement oversight of the Special Investigations Analytical Fraud Lead Program,  Desktop Procedures and Work Instructions to ensure they are up to date and accurately reflect the current workflows.
• Support investigative teams by providing actionable insights and data from fraud leads.
• Track the status of analytical leads and create detailed reports for leadership, including recommendations for process improvements.
• Ensure that workflows related to lead monitoring and investigation initiation are seamless and effective.
• Collaborate with investigative teams to ensure fraud leads are actionable and tracked accordingly.
• Identify training needs within the team and assist with developing training programs to address skill gaps and enhance overall team performance.
• Stay informed about industry trends, emerging fraud schemes, and regulatory changes to proactively adapt strategies and practices. 

Required Qualifications

• 8-10 years of experience in healthcare fraud investigations, claims operations, or analytics development.
• Strong understanding of medical, dental, and pharmacy claims processing, coding practices, and reimbursement methodologies.
• Proficiency and experience in project management
• Excellent organizational, analytical, and problem-solving skills.
• Strong written and verbal communication abilities, with experience presenting to leadership.
• Must be able to travel if required for testimony or training.

Preferred Qualifications

• Experience managing or monitoring fraud detection systems, tools, or leads.
• Medicare and Medicaid experience
• Project Management Experience

Education

• Bachelor’s degree in business administration, healthcare administration, Criminal Justice, or a related field or equivalent professional work experience.

Pay Range

The typical pay range for this role is:

$82,940.00 - $182,549.40

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.  This position also includes an award target in the company’s equity award program. 
 
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: 01/31/2025

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