Aetna Fraud Analyst in Farnborough, United States

Req ID: 49320BR

JOB FUNCTION

This position serves primarily as an analyst within the Fraud & Investigations Team. The job holder will support the Fraud & Investigations Team by demonstrating a high-level of independence in identifying trends, patterns, gaps, anomalies and inconsistencies in complex data sets and the provision of data driven intelligence for the Fraud & Investigations Team. The job holder will also be responsible for recoveries from duplicate payments and other overpayments by contacting providers and members where overpayments have occurred.

Decision Making Authority

Will operate under the direction of the Lead Fraud Investigator & ISIU Manager (ISIU) for decisions on both standard and non-routine matters. Will take ownership and use own judgement to develop methodologies and deliver detailed data and intelligence reports.

Context

  • Aetna International is committed to the prevention, detection and eradication of fraud in all its forms across the business.

  • The Financial Conduct Authority places a requirement on the business to ensure that it has in place adequate control to manage the fraud risk.

  • Fraud represents an un-quantified but considerable financial, reputational, regulatory and legal risk to InterGlobal, its assets and customers.

  • Ensuring that fraud controls are fully consistent with FCA standards including Treating Customers Fairly requirements.

KEY RESPONSIBILITIES

  • Develop and deliver full data analysis capability to support fraud investigation across claims and other operational areas.

  • Produce and maintain fraud MI as required by the business/group or as directed by the Lead Fraud Investigator & ISIU Manager.

  • Review of Reimbursement invoices for more than $2500 and feedback in 24 hours to referrer.

  • Prepare clear concise reports to support findings regarding potential fraud, waste or abuse.

  • Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in policy and initiate appropriate action.

  • Contacting providers and members for recovery of duplicates and overpayments and recording these on a ledger, following agreed process and SLA s on recoveries.

  • Maintaining a daily and weekly checking log of members under investigation and review of claims submitted.

  • If required appear as a witness on behalf of the company in civil and criminal proceedings.

  • Assist with the delivery of a full range of counter fraud work across the Group.

PRINCIPAL CONTACTS

Internally: Internal Departments and teams, Group Heads, Customer departments.

Externally: Medical Personnel, Members, Service Providers, Regulatory bodies.

EDUCATION & EXPERIENCE

· Demonstrates analytical thinking skills.

· Possesses excellent written and oral communication skills.

· Demonstrates strong organisational and prioritisation skills with ability to manage multiple priorities effectively.

· Ability to effectively collaborate with key business areas.

· An understanding of market practices in areas affecting the role.

· An understanding of industry fraud activity and best practice.

· Strong sense of initiative and drive and the willingness to self-start activities.

· Ability to build relationships between teams within the business.

· Strong communications/interpersonal skills including negotiation and influencing skills.

· Presentation skills.

· Report writing.

· Ability to deliver projects on specific subjects.

· Highly PC literate with good keyboard skills.

Critical

Knowledge of all underwriting types, Actisure processes, Excel skills

Desirable

Medical knowledge or awareness, knowledge of claims and coding

Knowledge of insurance fraud and other forms of financial crime.

Any other relevant qualification

PERSONAL CHARACTERISTICS

§ Should be adaptable and able to work on own with minimal supervision.

§ The role needs a high level of organisational and inter-personal skills.

§ The individual will need to demonstrate initiative and be able to prioritise varied and important tasks.

§ Able to respond to team objectives.

§ Willingness to travel if required.

§ Team player.

§ Flexible.

§ Willingness to learn and develop new skills.