Are you a highly skilled and detail-oriented Certified Professional Coder with a passion for healthcare fraud detection and prevention? Do you excel at leading a team and utilizing your clinical coding expertise to identify and investigate potential instances of fraud? If so, we have an exciting opportunity for you to join our team as the Special Investigation Unit Manager Clinical Certified Professional Coder at CVS Health, specifically with our Aetna SIU team. In this role, you will play a critical role in ensuring the integrity of our healthcare system by managing investigations and implementing strategies to combat fraudulent activities. To be successful in this role, you must possess a deep understanding of clinical coding principles and be able to effectively communicate and collaborate with cross-functional teams. Join us in our mission to make healthcare safer and more affordable for all.
Lead and manage a team responsible for investigating potential instances of healthcare fraud within the organization.
Utilize expert knowledge of clinical coding principles to identify and analyze potential fraudulent activities.
Develop and implement strategies to prevent and detect healthcare fraud, waste, and abuse.
Collaborate with cross-functional teams to ensure timely and accurate identification of potential fraud cases.
Develop and maintain relationships with external stakeholders, such as law enforcement agencies and regulatory bodies, to support fraud investigations.
Conduct thorough and detailed investigations, including reviewing medical records, claims data, and other relevant information.
Stay up to date on industry trends and changes in coding regulations to ensure compliance and effectiveness of fraud detection strategies.
Communicate findings and recommendations to senior leadership and other stakeholders in a clear, concise, and timely manner.
Develop and maintain a system for tracking and reporting on fraud investigations and outcomes.
Provide guidance and training to team members on coding principles and fraud detection techniques.
Ensure adherence to all relevant laws, regulations, and company policies related to healthcare fraud and abuse.
Maintain confidentiality and handle sensitive information with discretion and integrity.
Collaborate with internal and external auditors to support audits related to fraud investigations.
Continuously evaluate and improve fraud detection processes and procedures to enhance the effectiveness of the SIU team.
Foster a culture of compliance and integrity within the team and the organization as a whole.
CVS Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based upon race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.