Aetna SIU Investigator in Hartford, Connecticut

Req ID: 43621BR

POSITION SUMMARY

Under the direction of the Director of Special Investigations to prevent, detect and investigate known or suspected acts of fraud, waste, or abuse, and acts of a criminal nature that involve Aetna Providers/Members fraud for the purpose of protecting the employees, assets and resources of the Company.

Fundamental Components:

Conducts investigations of known or suspected acts of healthcare/disability fraud and abuse, Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases, Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc., Provides input regarding controls for monitoring fraud related issues within the business units, Maintains open communication with constituents within and external to the company, Uses available resources and technology in developing evidence and supporting allegations of fraud and abuse, Researches and prepares cases for clinical and legal review, Documents all appropriate case activity in tracking system,Makes referrals, both internal and external, in the required timeframe, Exhibits behaviors outlined in Employee Competencies, Exhibits behaviors outlined in SIU Investigator Competencies

BACKGROUND/EXPERIENCE desired:

Experience in insurance claims investigation or professional/clinical experience, Investigative experience, preferably in the area of healthcare/disability fraud and abuse. Strong analytical and research skills, Proficient in researching information and identifying informational resources, CPC licensure a plus

EDUCATION

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

FUNCTIONAL EXPERIENCES

Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years

Functional - Claims/Policies & procedures/1-3 Years

Functional - Products-Medical/Miscellaneous Plans/1-3 Years

TECHNOLOGY EXPERIENCES

Technical - Aetna Applications/ACAS - CDL LCI/1-3 Years/End User

Technical - Aetna Applications/ClaimXten (McKesson software)/1-3 Years/End User

Technical - Aetna Applications/Enterprise Provider Database System/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/ADVANCED

Technology/Leveraging Technology/FOUNDATION

Telework Specifications:

Considered only for current internal teleworkers (in any area)

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.

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

Aetna takes our candidate'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