Aetna Meritain SIU Sr Investigator in Tampa, Florida

Req ID: 41022BR

POSITION SUMMARY

Conducts more high level, complex investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud, waste and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices

Fundamental Components:

Conducts 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 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 Meritain's approach to fighting fraud*

Reviews pre-specified claims for potential high level fraudulent activity to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc, and returns them to the claim operation sites for proper adjudication.(*)

Provides input regarding controls for monitoring fraud related issues within the business units*

Utilizes Medical Directors and other Aetna personnel to clarify medical necessity and billing appropriateness.(*)

Conducts fact-finding research, gathers relevant information, evaluates and extracts pertinent investigative data and develops materials in detailed format to ensure evidence is fully supportable.(*)

BACKGROUND/EXPERIENCE desired:

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

EDUCATION

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

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/MASTERY

General Business/Turning Data into Information/ADVANCED

DESIRED SKILLS

Leadership/Collaborating for Results/ADVANCED

Leadership/Driving a Culture of Compliance/MASTERY

Leadership/Driving Change/FOUNDATION

ADDITIONAL JOB INFORMATION

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.

Knowledge of Aetna's policies and procedures.

Exercises independent judgment and uses available resources and technology in developing evidence, supporting allegations for fraud, waste 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