Aetna SIU Sr Investigator in Tampa, Florida

Req ID: 53005BR

POSITION SUMMARY

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 practice.

Fundamental Components:

  • 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 insureds, 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.

BACKGROUND/EXPERIENCE desired:

3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters.

Strong analytical and research skills. Proficient in researching information and identifying information resources.

Strong communication and customer service skills. Ability to effectively interact with different groups of people at different levels in any situation.

Competent with legal theories.

Knowledge and understanding of complex clinical issues.

Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.

Exercises independent judgment and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.

EDUCATION

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

LICENSES AND CERTIFICATIONS

Forensic/American College of Forensic Examiners is desired

Medical/Certified Coding Associate (CCA) is desired

FUNCTIONAL EXPERIENCES

Functional - Claims/Overpayment recovery/1-3 Years

Functional - Risk Management/Investigative services/1-3 Years

FunctionalExperience/FunctionalFocus/1-3 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Exchange/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/MASTERY

General Business/Demonstrating Business and Industry Acumen/ADVANCED

ADDITIONAL JOB INFORMATION

  • Opportunity to collaborate with the various parties to eradicate Fraud, Waste, and Abuse.

  • Opportunity to join a collaborative, engaging, and great working environment and team.

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: 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.