Healthcare Fraud Manager (Pharmacy/Broker/Dental) (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 We are seeking an experienced Healthcare Fraud Manager to lead and oversee a team of investigators in our efforts to identify, prevent, and mitigate healthcare fraud, waste and abuse. This role involves not only directing fraud detection and investigation activities but also developing strategies to minimize fraud risks, ensuring compliance with regulatory standards, and achieving operational productivity goals. The ideal candidate will possess strong leadership and analytical skills, a deep understanding of healthcare fraud schemes and the ability to adapt quickly to emerging fraud trends. Key Responsibilities Provide leadership, guidance, and support to a team of investigators, fostering a collaborative and productive work environment. Direct and oversee all fraud detection activities and investigations, ensuring alignment with organizational objectives and compliance standards. Stay informed on latest fraud schemes and trends, adapting strategies and responses as needed to address new threats effectively. Work closely with investigative management and directors, sharing insights and aligning on fraud prevention and mitigation strategies. Create and implement strategies to proactively address and minimize fraud risks. Monitor team productivity and ensure investigative processes meet organizational productivity goals. Communicate findings, recommendations, and strategies effectively to senior leadership and relevant stakeholders. Ensure compliance with regulatory requirements and maintain standards across all investigation and fraud prevention activities. Develop and mentor team members, providing opportunities for professional growth and development. Foster a culture of continuous improvement and innovation within the team. Required Qualifications Minimum of three years managing healthcare fraud, waste and abuse investigations and audits. 7-10 years of experience in fraud investigations within the healthcare sector. Strong analytical and problem-solving skills with experience in data analysis and fraud detection. In-depth knowledge of healthcare fraud schemes, regulatory standards, and compliance requirements. Excellent communication and leadership skills. Preferred Qualifications Pharmacy Investigation experience Dental Investigation experience Broker Investigative experience in the Medicare and the Marketplace Team management experience. Education: Bachelors degree in Criminal Justice or related field or equivalent professional work experience. Pay Range The typical pay range for this role is: $66,330.00 - $145,860.00 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 Companys 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: 03/24/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply Job!