Job Description

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 3-5 years investigative experience in the area of Healthcare and Pharmacy fraud, waste and abuse. Knowledge of Pharmacy and Medical terminology. Experience with Microsoft Office products, specifically Microsoft Excel, and Database search tools. Proficient in data analysis and research. Ability to travel and participate in legal proceedings, arbitrations, depositions, etc. Preferred Qualifications Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI) Bilingual in English/Spanish Strong verbal and written communication skills. Strong customer service skills. Knowledge of CVS/Aetna's policies and procedures Ability to interact with different groups of people at different levels. Ability to utilize company systems to obtain relevant electronic documentation. Education Bachelor's degree in Criminal Justice preferred or equivalent experience Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 - $112,200.00 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. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments ( Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran — committed to diversity in the workplace. #J-18808-Ljbffr

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