Aetna Lead Analytics Consultant - Fraud Waste Abuse in Blue Bell, Pennsylvania

Req ID: 56025BR

POSITION SUMMARY

The Fraud analytics team is looking for an Informatics clinical consultant who is skilled at utilizing healthcare claims data to identify outliers. The ideal candidate retrieves, organizes and performs analysis on healthcare data and also guide the team to develop, validate and deploy business rules indicative of FWA or payment integrity. This position requires extensive knowledge of healthcare claims and will work on identifying opportunities and delivering clinical/coding insights with internal and external teams.

Fundamental Components:

  • Consults and lends clinical expertise to internal clients and colleagues

  • Consults with internal clients to identify opportunities to implement data science solutions for business problems

  • Ability to structure data analysis, driving analytics insights and analytical solutions to help the internal team develop simple to complex business rules

  • Validation and deployment of algorithms or business rules developed to identify outlier billing patterns within claims data that may be indicative of FWA or payment errors

  • Provide clear and concise feedback on any coding changes that are required

  • Keep current with new & emerging fraud, waste and abuse schemes and trends through training sessions and industry resources

  • Interprets, analyzes and presents key findings to internal team or business partners

  • Providing recommendations based on analytical findings

  • Collaborates with business partners to understand their strategy, problems, and goals

BACKGROUND/EXPERIENCE desired:

Minimum 5-7 yrs. in Fraud, waste or Abuse (or Payment Integrity)

5+ years experience in clinical coding or consulting

Certified Professional Code preferred

Experience in SAS or SQL or other programming languages

Demonstrates strong ability to communicate clinical concepts and implications to business partners

EDUCATION

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

ADDITIONAL JOB INFORMATION

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Data & Analytics

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.