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
Conducts high level, complex analysis of Pharmacy and Prescriber behavior to effectively pursue the prevention, investigation and prosecution of Fraud Waste and Abuse.

• Collaboration with Pharmacy Benefit Manager, providing meaningful evidence of Fraud, Waste and Abuse to support Pharmacy Audit activities.
• Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving Pharmacies and Prescribers.
• Investigates to prevent payment of fraudulent activities committed by Pharmacies and Prescribers.
• Researches and prepares cases for clinical, legal and leadership review.
• Documents all appropriate case activity in case tracking system.
• Makes referrals, both internal and external, in the required timeframe.
• Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution.
• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings.
• Gives presentations to internal and external customers regarding Pharmacy Fraud matters.
• Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units.
• Maintains open communication with constituents within and external to the company.

Required Qualifications

Strong knowledge of Pharmacy and Medical terminology.

Advanced skills with Microsoft Excel.

Experience in healthcare/pharmacy insurance claims investigation.

Proficient in data analysis and research.

Proficiency in MS Office products, Database search tools.

Strong verbal and written communication skills.

Strong customer service skills.

Ability to interact with different groups of people at different levels.

Ability to utilize company systems to obtain relevant electronic documentation.

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

Preferred Qualifications

AHFI, CFE

Bilingual in English/Spanish

Knowledge of CVS/Aetna's policies and procedures

Education

Bachelor's Degree in Criminal Justice or equivalent experience

Pay Range

The typical pay range for this role is:

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 jobs.CVSHealth.com/benefits