Aetna CA MCD SIU Sr Investigator in San Diego, California

Req ID: 45087BR


The SIU Sr. Investigator 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:

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*


3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters. College degree in Criminal Justice or a related field. Strong analytical and research skills. Proficient in researching information and identifying information resources. Strong communication/customer service skills. Ability to effectively interact with different groups of people/situations.


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


Functional - Risk Management/Investigative services/4-6 Years

Functional - Legal/Special investigations/4-6 Years


Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User

Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/End User


Finance/Managing Aetnas Risk/ADVANCED

General Business/Communicating for Impact/MASTERY

General Business/Demonstrating Business and Industry Acumen/ADVANCED


General Business/Maximizing Work Practices/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Technology/Leveraging Technology/FOUNDATION


Additional background/experience: 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. Knowledge of Aetna's policies and procedures. Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations fo fraud and abuse.

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