Quality Reviewer (Aetna SIU) at CVS Health in Boise, Idaho, United States Job Description Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. Position Summary + Assess the thoroughness and accuracy of investigations aimed at preventing payment of fraudulent claims by insured individuals, providers, claimants, etc. + Analyze and prepare cases for clinical and legal review, ensuring all documentation meets required standards. + Document all relevant case activity in the case tracking system. + Evaluate and present referrals, both internal and external, within the required timeframe. + Support the recovery of company funds lost due to fraud by providing insights and recommendations based on case reviews. + Collaborate with the team to identify resources and the best course of action for ongoing investigations. + Work with federal, state, and local law enforcement agencies to ensure compliance and support the prosecution of healthcare fraud and abuse matters. + Demonstrate a high level of knowledge and expertise during interactions and provide confident testimony during civil and criminal proceedings. + Deliver presentations to internal and external stakeholders regarding healthcare fraud matters and the organization's approach to combating fraud. + Provide input on controls for monitoring fraud-related issues within business units. + Exercise independent judgment and utilize available resources and technology to develop evidence supporting allegations of fraud and abuse. + Utilize company systems to obtain necessary electronic documentation. Required Qualifications + A minimum of 3 years of experience in healthcare within auditing, compliance, or fraud, waste and abuse. + Knowledge of CPT/HCPCS/ICD coding. + Proficiency in Microsoft Word, Excel, Outlook, database search tools, and internet research. + Willingness to travel and participate in legal proceedings, arbitrations, depositio To view full details and how to apply, please login or create a Job Seeker account
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