Experienced Special Investigations Senior Manager Productivity Leader – Healthcare Fraud Detection and Prevention Expert

Introduction to CVS Health and Our Mission At CVS Health, we are driven by a singular purpose: to bring our heart to every moment of your health. This guiding principle is at the core of our commitment to delivering human-centric healthcare in a rapidly changing world. Our brand, with heart at its center, sends a personal message that how we deliver our services is just as important as what we deliver. We are seeking an experienced and highly analytical Senior Manager to join our Special Investigations Unit, where you will play a critical role in leading the oversight and implementation of productivity requirements and compliance. Job Overview As a Senior Manager in the Special Investigations Unit, you will be responsible for developing and implementing strategic initiatives to enhance the effectiveness of fraud detection and prevention efforts. You will monitor and evaluate the performance of SIU investigative staff and productivity metrics, ensuring operational rigor and identifying opportunities for improvement. Your expertise in medical, dental, and pharmacy claims operations, as well as your understanding of coding practices and emerging fraud trends, will be essential in driving success in this role. Key Responsibilities Develop and implement strategic initiatives to enhance the effectiveness of fraud detection and prevention efforts within the SIU Monitor and evaluate the performance of SIU investigative staff and productivity metrics to ensure operational rigor Implement oversight of the Special Investigations Hub, Desktop Procedures, and Work Instructions to ensure they are up to date and accurately reflect current workflows Support investigative teams by providing actionable insights and data from fraud leads Track the status of analytical leads and create detailed reports for leadership, including recommendations for process improvements Ensure that workflows related to lead monitoring and investigation initiation are seamless and effective Collaborate with investigative teams to ensure fraud leads are actionable and tracked accordingly Identify training needs within the team and assist with developing training programs to address skill gaps and enhance overall team performance Stay informed about industry trends, emerging fraud schemes, and regulatory changes to proactively adapt strategies and practices Essential Qualifications To be successful in this role, you will need: 8-10 years of experience in healthcare fraud investigations, claims operations, or analytics development A strong understanding of medical, dental, and pharmacy claims processing, coding practices, and reimbursement methodologies Proficiency and experience in project management Excellent organizational, analytical, and problem-solving skills Strong written and verbal communication abilities, with experience presenting to leadership The ability to travel if required for testimony or training Preferred Qualifications While not required, the following qualifications are preferred: Experience managing or monitoring investigative productivity metrics and operational requirements for all lines of business A Bachelor's Degree or equivalent professional work experience Skills and Competencies To excel in this role, you will need to possess a range of skills and competencies, including: Strong analytical and problem-solving skills, with the ability to analyze complex data and identify trends and patterns Excellent communication and interpersonal skills, with the ability to build strong relationships with stakeholders and team members Strong project management skills, with the ability to prioritize tasks and manage multiple projects simultaneously A strong understanding of the healthcare industry, including medical, dental, and pharmacy claims operations and coding practices The ability to stay up to date with industry trends, emerging fraud schemes, and regulatory changes Career Growth Opportunities and Learning Benefits At CVS Health, we are committed to supporting the growth and development of our employees. As a Senior Manager in the Special Investigations Unit, you will have access to a range of career growth opportunities and learning benefits, including: Professional development programs, including training and education opportunities Leadership development programs, including mentorship and coaching Opportunities for advancement, including promotions and lateral moves A comprehensive benefits package, including medical, dental, and vision benefits, as well as a 401(k) retirement savings plan and an Employee Stock Purchase Plan Work Environment and Company Culture At CVS Health, we are proud of our company culture, which is built on a foundation of values including integrity, respect, and accountability. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful, and we are committed to creating a work environment that is inclusive, supportive, and empowering. As a Senior Manager in the Special Investigations Unit, you will be part of a team that is dedicated to making a difference in the lives of our customers and patients. Compensation, Perks, and Benefits The typical pay range for this role is $82,940.00 - $182,549.40, depending on experience and location. In addition to your salary, you will be eligible for a range of perks and benefits, including: A comprehensive benefits package, including medical, dental, and vision benefits A 401(k) retirement savings plan and an Employee Stock Purchase Plan Paid Time Off (PTO) or vacation pay, as well as paid holidays throughout the calendar year A range of well-being programs, including education assistance, free development courses, and a CVS store discount Discount programs with participating partners Conclusion If you are a motivated and experienced professional looking for a challenging and rewarding role, we encourage you to apply for the Special Investigations Senior Manager Productivity position. As a member of our team, you will have the opportunity to make a real difference in the lives of our customers and patients, while also growing and developing your skills and career. Don't miss out on this exciting opportunity – apply today! Apply for this job