Massachusetts Jobs

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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

The Special Investigations Unit is seeking a Sr. Manager to lead our new ASO investigations team.

The Healthcare Fraud Senior Manager is responsible for overseeing and managing fraud detection, investigation, and prevention efforts to safeguard the organization’s resources and reduce healthcare costs. This role involves leading a team of investigators working closely with internal and external stakeholders and ensuring compliance with regulatory requirements. The Senior Manager develops strategies to mitigate fraud risks, analyzes complex data to identify potential fraud schemes, and directs investigations to resolve issues effectively.

*This is a hybrid role that will require to go into any office location three times a week. Hartford location or East Coast hub locations preferred.

Key Responsibilities:

Leadership and Team Management:

• Lead and mentor a team (approximately 5) of fraud investigators, analysts, and other staff, providing guidance and support in fraud detection and prevention efforts.

• Establish team goals, monitor performance, and ensure alignment with organizational objectives.

Fraud Detection and Prevention:

• Work closely with analytics team to contribute to the development of fraud detection strategies using data analytics, machine learning, and other advanced techniques to identify patterns of fraudulent behavior.

• Conduct risk assessments to identify vulnerabilities in the organization’s processes and implement measures to mitigate these risks. Design and manage proactive fraud prevention programs to minimize exposure to fraudulent activities.

Investigation Management:

• Direct and oversee complex investigations into suspected healthcare fraud, waste, and abuse.

• Ensure timely and accurate reporting of investigation findings and coordinate with legal and compliance teams to take appropriate action.

• Collaborate with law enforcement agencies, regulatory bodies, and external partners during investigations when necessary.

• Prepare comprehensive reports summarizing investigation outcomes, risk assessments, and fraud trends.

Compliance and Regulatory Adherence:

• Ensure all fraud investigation and prevention activities comply with state, federal, and industry regulations.

• Stay informed about changes in laws, regulations, and industry practices related to healthcare fraud.

• Assist in preparing documentation for audits, compliance reviews, and regulatory inquiries.

Skills:

• Strong leadership and team management ability

• Excellent communication and presentation skills.

• Ability to work cross-functionally with various teams and external partners.

Required Qualifications:

• Minimum 7+ years of experience in healthcare fraud detection, investigation, or auditing

• In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.

Preferred Qualifications:

• Minimum 3+ years in a leadership role.

• Relevant certifications (e.g., Certified Fraud Examiner (CFE), accredited healthcare fraud investigator (AHFI)

Education:

• Bachelor's degree preferred in healthcare administration, finance, criminal justice, or related field/specialized training/relevant professional qualification.

Pay Range

The typical pay range for this role is:

$75,400.00 - $199,144.80

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 (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 11/18/2024

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

We are an equal opportunity and affirmative action employer. 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.