Quality Reviewer (Aetna SIU)

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 • Assess the thoroughness and accuracy of investigations aimed at preventing payment of fraudulent claims by insured individuals, providers, claimants, etc. • Analyze and prepare cases for clinical and legal review, ensuring all documentation meets required standards. • Document all relevant case activity in the case tracking system. • Evaluate and present referrals, both internal and external, within the required timeframe. • Support the recovery of company funds lost due to fraud by providing insights and recommendations based on case reviews. • Collaborate with the team to identify resources and the best course of action for ongoing investigations. • Work with federal, state, and local law enforcement agencies to ensure compliance and support the prosecution of healthcare fraud and abuse matters. • Demonstrate a high level of knowledge and expertise during interactions and provide confident testimony during civil and criminal proceedings. • Deliver presentations to internal and external stakeholders regarding healthcare fraud matters and the organization’s approach to combating fraud. • Provide input on controls for monitoring fraud-related issues within business units. • Exercise independent judgment and utilize available resources and technology to develop evidence supporting allegations of fraud and abuse. • Utilize company systems to obtain necessary electronic documentation. Required Qualifications • A minimum of 3 years of experience in healthcare within auditing, compliance, or fraud, waste and abuse. • Knowledge of CPT/HCPCS/ICD coding. • Proficiency in Microsoft Word, Excel, Outlook, database search tools, and internet research. • Willingness to travel and participate in legal proceedings, arbitrations, depositions, etc. Preferred Qualifications • Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or a minimum of three years of Medicaid Fraud, Waste, and Abuse review experience. • Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA). • Knowledge of Behavioral Health policies and procedures is a plus. • Experience reviewing Behavioral Health fraud cases. • Understanding of clinical issues related to healthcare. • Strong communication and customer service skills. • Ability to effectively interact with diverse groups of people at various levels in any situation. • Strong analytical and research skills using healthcare data. • Proficient in researching information and identifying relevant resources. Education • A Bachelors degree or three years of experience in healthcare fraud, waste, and abuse investigations and audits. Pay Range The typical pay range for this role is: $43,888.00 - $102,081.60 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: 12/27/2024 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply Job!