Job Description

At CVS Health, were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nations leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Medical Director - SIU (Special Investigations Unit)

CVS Health - Special Investigations Unit (SIU)

Join our mission to safeguard healthcare integrity and protect patient well-being. As the Medical Director of Healthcare Fraud Investigations, you'll lead our efforts to detect, prevent, and combat fraudulent activities in the healthcare system.

**This is a remote based, work from home role.**

Key Responsibilities:

The Special Investigations Unit (SIU) Medical Director will be responsible for performing reviews of medical records in support of healthcare fraud investigations . Serving as a clinical liaison supporting SIU activities across all lines of business the SIU Medical Director will be responsible for making both pre and post-payment claim payment determinations based on Aetna Clinical Policy and/or state and federal regulations . Additional responsibilities include:

• Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors in matters pertaining to the investigation of suspected healthcare fraud cases

• Develops and delivers presentations to internal and external customers regarding healthcare fraud matters and Aetnas approach to fighting fraud .

• Provides clinical expertise and business direction in the creation of analytical solutions designed to identify potentially fraudulent scenarios

• Maintains open communication with constituents within and external to the organization

• Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, or abuse

• Documents all appropriate information related to medical review determinations

• Proactively build s relationships with other internal MDs to obtain clinical guidance when required to ensure accurate decision making

• Represents Aetna as a witness in legal matters as required , and as approved by the Legal Department . Demonstrates high level of knowledge and acts confidently when providing testimony during civil or criminal proceedings.

• Responsible for peer to peer reviews of SIU related claims based on provider escalation or state/federal requirements

• Supports legal efforts by providing expert medical testimony and

• Conducts root cause analysis to identify potential control gaps in the organizations existing clinical policy, procedures, claim editing etc., and proactively seeks out appropriate contacts to help implement solutions.

• Mentor and educate SIU team members on clinical aspects of fraud schemes

Required Qualifications:

• MD or DO with active license , preferably in emergency medicine or primary care

• 5+ years of clinical practice experience

• Strong analytical and problem-solving skills

• Excellent communication and leadership abilities

Preferred Qualifications:

• 3+ years supporting healthcare fraud investigation s or related field

• Board Certification in Emergency Medicine

Education:

• Active and current state medical license without encumbrances
• M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience

Pay Range

The typical pay range for this role is:

$174,070.00 - $374,920.00

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. This position also includes an award target in the companys equity award program.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit

We anticipate the application window for this opening will close on: 07/28/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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Job Tags

Hourly pay, Full time, Temporary work, Local area, Remote work, Flexible hours,

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