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
The Behavioral Health Senior Investigator is responsible for conducting complex investigations involving Applied Behavior Analysis (ABA) services and behavioral health providers to identify, detect, and prevent potential fraud, waste, and abuse (FWA). This position utilizes clinical and investigative knowledge to analyze provider billing patterns, service utilization, treatment documentation, and regulatory compliance to identify aberrant activity and support investigative outcomes.
Fraud, Waste & Abuse (FWA) Investigation Responsibilities
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Conduct behavioral health and ABA-retrospective reviews to identify potential fraud, waste, abuse, and quality of care concerns.
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Analyze clinical documentation, treatment plans, progress notes, billing records, and utilization patterns for indicators of inappropriate services, overutilization, unbundling, duplicate billing, or services not supported by clinical documentation.
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Partner with Special Investigations Unit (SIU), Compliance, Legal, Network, and Medical Management teams to support investigations involving ABA providers, behavioral health practitioners, and related service providers.
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Perform clinical reviews and provide subject matter expertise regarding ABA standards of care, medical necessity, and treatment appropriateness.
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Identify emerging fraud schemes, billing anomalies, and provider outlier trends through data analysis and case review activities.
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Prepare concise investigative summaries, clinical findings, and recommendations for internal stakeholders and leadership.
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Participate in provider audits, site visits, record reviews, and corrective action initiatives as needed.
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Support recovery, prepayment review, and provider education efforts when inappropriate billing or service delivery concerns are identified.
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Ensure investigations and reviews comply with applicable regulatory requirements, payer policies, BACB ethical standards, state regulations, and organizational compliance expectations.
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Contribute to the development of fraud prevention strategies, provider education materials, and investigative business rules designed to detect and mitigate fraud, waste, and abuse.
Required Qualifications
Preferred Qualifications
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Experience working with Autism Spectrum Disorder (ASD) populations.
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Knowledge of healthcare, managed care, or behavioral health systems.
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Experience in interdisciplinary care coordination.
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Experience supporting healthcare fraud, waste, and abuse (FWA) investigations.
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Knowledge of healthcare claims, coding, reimbursement methodologies, and payer audit processes.
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Experience conducting provider record reviews, utilization analysis, or compliance audits.
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Familiarity with Medicaid, Medicare, commercial health plan operations, and behavioral health reimbursement practices.
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Strong analytical, communication, and organizational skills.
Education
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Master’s degree in Applied Behavior Analysis, Psychology, Education, Special Education, or a related field.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00
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.
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: 09/26/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
