Aetna SIU Sr. Investigator in Louisville, Kentucky
Req ID: 71196BR
Conducts more high level, complex investigations to effectively pursue the prevention, investigation and prosecution of healthcare and disability fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices
Fundamental Components included but are not limited to:
Conducts more high level, complex investigations of known or suspected acts of healthcare/disability fraud and abuse. Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes* Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc* Researches and prepares cases for clinical and legal review* Documents all appropriate case activity in case tracking system* Makes referrals, both internal and external, in the required timeframe* Facilitates the recovery of company and customer money lost as a result of fraud matters* Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators. Assists Investigators in identifying resources and best course of action on investigations* Serves as back up to the Team Leader as necessary Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings* Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud* Provides input regarding controls for monitoring fraud related issues within the business units*
Qualifications Requirements and Preferences:
3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters. College degree in Criminal Justice or a related field preferred.
Additional Job Information:
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations fo fraud and abuse.Knowledge of Aetna's policies and procedures.Knowledge and understanding of complex clinical issues.Competent with legal theories.Strong communication and customer service skills. Ability to effectively interact with different groups of people at different levels in any situation.Strong analytical and research skills. Proficient in researching information and identifying information resources.Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
Benefit eligibility may vary by position.
Job Function: Legal
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.