Job Description

Medical Director - SIU (Special Investigations Unit) At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s 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. Medical Director - SIU (Special Investigations Unit) 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 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 Aetna’s 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 builds 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 organization’s 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 investigations 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. Great Benefits For Great People 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. We anticipate the application window for this opening will close on: 10/30/2025 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

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