CVS Health Senior Investigator, Special Investigations Unit (Aetna SIU) Customer Care

Description

CVS Health is hiring for a Senior Investigator position within the Aetna Special Investigations Unit (SIU). This role focuses on investigating suspected healthcare fraud, waste, and abuse (FWA) and helping prevent improper payments.

The position is designed for experienced healthcare fraud investigators who can research complex cases, analyze healthcare information, prepare evidence for clinical and legal review, and communicate findings with different teams and external organizations.

The role can be performed remotely, although travel may be required for business needs, investigations, legal proceedings, or other work-related activities. The position is best suited to professionals with several years of healthcare fraud and abuse investigation experience.

Job at a Glance

Job Title	Senior Investigator, Special Investigations Unit (Aetna SIU)
Company	CVS Health
Location	Remote / Work From Home
Job Type	Full-Time
Experience	3–5 years in healthcare fraud, waste, and abuse investigations
Industry	Healthcare
Job Category	Investigation / Healthcare Compliance
Main Focus	Healthcare fraud, waste, abuse, claims investigation, research and case development
Salary	Approximately $46,988–$122,400 per year, depending on the specific job location and other factors

Detailed Role Requirements & Responsibilities

Healthcare Fraud Investigations

The Senior Investigator handles complex investigations involving suspected or known healthcare fraud, waste, and abuse. The work can involve reviewing claims, researching individuals or organizations, identifying unusual activity, and developing evidence to support an investigation.

Claims and Data Research

A major part of the job involves examining healthcare information and identifying patterns that may indicate improper billing or fraudulent activity. Strong investigators need to be comfortable working with large amounts of information and finding connections that may not be immediately obvious.

Some versions of this role also emphasize proactive data mining and analysis of claims data to identify unusual billing patterns or potential schemes.

Case Preparation

Investigators prepare cases for clinical and legal review. This includes documenting investigation activity, organizing evidence, preparing written case summaries, and making appropriate internal or external referrals within required timeframes.

Fraud Recovery and Referrals

The role can involve helping recover money lost through fraud and supporting referrals to appropriate state or federal agencies. Investigators may also work with law enforcement agencies when healthcare fraud cases move toward prosecution.

Communication and Presentations

The Senior Investigator may communicate findings to internal teams, external partners, customers, clinical staff, legal teams, and other stakeholders. The position can also require presentations about investigations and healthcare fraud matters.

Strong written and verbal communication is therefore important, especially when explaining complicated findings in a clear way.

Legal Proceedings

Depending on the investigation, the role may involve participating in legal proceedings, arbitrations, depositions, or providing testimony in civil or criminal cases. Candidates should be comfortable presenting investigation findings and supporting evidence when required.

Independent Investigation

This is not simply a data-entry or case-processing position. Senior Investigators are expected to use independent judgment, identify useful sources of information, develop evidence, and determine appropriate investigation steps.

Required Skills and Experience

Candidates should be prepared to demonstrate:

• 3–5 years of experience investigating healthcare fraud, waste, and abuse.
• Strong research and analytical skills.
• Experience working with healthcare data and investigation records.
• Knowledge of medical coding such as CPT, HCPCS, and ICD-10 can be important for related versions of this role.
• Strong Microsoft Office skills, particularly Word, Excel, and Outlook.
• Ability to use database search tools and internet or intranet research resources.
• Ability to identify relevant information and develop evidence.
• Strong written and verbal communication skills.
• Ability to work independently and make sound decisions.
• Ability to travel when required.

Skills That Can Strengthen Your Application

Certain qualifications can make a candidate more competitive for an Aetna SIU investigator position:

• Certified Fraud Examiner (CFE)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Professional Coder (CPC)
• CCS or other relevant medical coding credentials
• Medicaid or Medicare investigation experience
• Healthcare claims investigation experience
• Knowledge of Aetna policies and procedures
• Knowledge of self-funded insurance plans
• Advanced Excel skills, including pivot tables
• Experience with claims data analysis
• Knowledge of clinical issues
• Experience working with law enforcement or legal teams
• Strong presentation and stakeholder communication skills

Industry Context & Career Advice

Healthcare fraud investigation combines healthcare knowledge, data analysis, research, compliance, and investigative work. Investigators may examine claims and billing activity to identify patterns that could indicate fraud or abuse.

For someone already working in healthcare auditing, claims, medical coding, compliance, or fraud investigations, an SIU role can be a strong career progression. Experience with healthcare data is especially useful because investigators need to understand both the numbers and the medical context behind a claim.

If you want to move into healthcare fraud investigation, start by building experience in claims review, medical coding, healthcare compliance, auditing, or investigations. Certifications such as CFE, AHFI, or CPC can also help demonstrate specialized knowledge.

What to Highlight on Your Resume

Your resume should make your investigation experience easy to find. Focus on:

• Healthcare fraud, waste, and abuse investigations
• Claims analysis and suspicious billing patterns
• Healthcare auditing
• Medical coding knowledge
• Research and evidence gathering
• Case documentation
• Regulatory compliance
• Medicaid or Medicare experience
• Legal or clinical case preparation
• Microsoft Excel and data analysis
• Communication with providers, customers, clinical teams, or legal departments
• Presentations and investigation findings

A stronger resume bullet could be:

Conducted complex healthcare fraud and abuse investigations by analyzing claims data, researching subjects and related entities, documenting evidence, and preparing cases for clinical and legal review.

If you have used Excel for claims analysis, make that specific. Instead of simply writing “Microsoft Excel,” mention the actual work you performed, such as pivot tables, data analysis, trend identification, or investigation reporting.

Interview Preparation

Prepare for questions that test both your investigation skills and your understanding of healthcare fraud.

How would you investigate a suspicious healthcare claim?

Explain how you would collect information, review the claim and related records, research the provider or subject, identify unusual patterns, document evidence, and determine the next step.

Tell us about a complex fraud investigation you handled.

Choose a real example and explain the problem, your investigation process, the evidence you found, and the final result.

How do you identify unusual patterns in healthcare claims?

Discuss the types of data you review and how you compare billing behavior, services, providers, patients, codes, dates, or other relevant information.

How do you maintain accurate investigation documentation?

Explain your process for recording evidence, communications, research findings, decisions, and case activity.

How comfortable are you with CPT, HCPCS, and ICD-10 codes?

Be prepared to explain your actual experience rather than simply listing the codes on your resume.

How do you handle sensitive information?

Healthcare investigations involve confidential information. Explain how you protect information, follow procedures, and limit access appropriately.

How would you explain complicated investigation findings to someone without an investigation background?

Show that you can turn complex data into a clear explanation supported by facts.

Advice for Applicants

This is a specialized senior-level position, so general healthcare experience alone may not be enough. The strongest candidates will be able to show direct experience with healthcare fraud, waste, and abuse investigations or closely related healthcare auditing work.

Make your resume evidence-based. Include the types of investigations you handled, the healthcare data you reviewed, the systems and research tools you used, and the results of your work.

If you have CFE, AHFI, CPC, CCS, Medicaid/Medicare, claims analysis, or healthcare coding experience, place those qualifications where recruiters can see them quickly.

The original CVS Health posting associated with this job is no longer accepting applications, so candidates should check CVS Health’s careers site for current Senior Investigator or Aetna SIU openings rather than relying on the closed requisition.

Benefits

Full-time CVS Health roles in this job family have included medical, dental and vision coverage, paid time off, retirement savings options, wellness programs, and other benefits based on eligibility.

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