Fraud, Waste & Abuse (FWA) Investigator - No Surprises Act (NSA)

Overview We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This individual contributor role supports complex investigations and contributes to organizational compliance with federal and state regulations. The position plays a key role in identifying fraud risks, supporting program integrity efforts, and helping to prevent financial losses related to fraud, waste, and abuse. Performs complex investigations related to healthcare fraud, waste, and abuse (FWA), with a focus on compliance with the No Surprises Act (NSA). This individual contributor role is responsible for analyzing healthcare data, conducting investigations, ensuring regulatory compliance, and supporting program integrity initiatives. Key Responsibilities Directs complex investigations, including data analysis, interviews, and document review, to identify potential fraud, waste, and abuse, including NSA-related activity. Conducts investigations into suspected fraud, waste, and abuse associated with the No Surprises Act (NSA), including independent dispute resolutions. Investigates dispute outcomes and identifies providers submitting non-NSA claims to CIDRE. Prioritizes and manages cases to ensure timely, accurate, and compliant investigations. Analyzes healthcare data and claims to identify patterns, trends, and anomalies indicative of fraud. Supports risk mitigation efforts and ensures compliance with regulatory requirements, including NSA provisions. Ensures investigative reports are accurate, complete, and compliant with legal and regulatory standards. Develops and delivers training on fraud, waste, and abuse prevention, including NSA requirements. Provides guidance and mentorship to team members during investigations. Advises management on fraud trends, regulatory changes, and best practices. Collaborates with internal partners and external stakeholders to support investigations. Partners with law enforcement, as appropriate, to support investigation and prosecution efforts. Maintains stakeholder communication and provides input on fraud risk controls. Required Qualifications 5+ years of experience in healthcare fraud, waste, and abuse investigations or related program integrity functions Experience analyzing healthcare claims data Knowledge of healthcare regulatory requirements Strong analytical, investigative, and problem-solving skills Ability to manage multiple priorities and meet established timelines Preferred Qualifications Experience with the No Surprises Act (NSA) Familiarity with CIDRE Experience working with regulatory agencies or law enforcement Certifications such as Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) Advanced knowledge of healthcare claims processing and billing practices Education Bachelor’s degree or equivalent combination of education and experience Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $66,330.00 - $145,860.00 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. 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. Benefits 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. We anticipate the application window for this opening will close on: 07/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr CVS Health