Aetna SIU Investigator in Columbus, Ohio
Req ID: 51703BR
Conducts 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.
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* Facilitates the recovery of company and customer money lost as a result of fraud matters* Provides input regarding controls for monitoring fraud related issues within the business units* Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company* Maintains open communication with constituents within and external to the company* Uses available resources and technology in developing evidence, 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 Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations Exhibits behaviors outlined in Employee Competencies Exhibits behaviors outlined in SIU Investigator Competencies
Must have healthcare claims experience; experience in insurance claims investigation or professional/clinical experience, background with law enforcement agencies; or seven years of professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims.
Investigative experience, preferably in the area of healthcare/disability fraud and abuse.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
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
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Communicating for Impact/ADVANCED
ADDITIONAL JOB INFORMATION
Strong analytical and research skills. Proficient in researching information and identifying information resources. Strong verbal and written communication skills. Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis. Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information. Ability to utilize company systems to obtain relevant electronic documentation. Knowledge of Aetna's policies and procedures.
Location: Full/time work at home position, unless located near Hartford CT, then in office and 2 to 3 days work at home.
Must be able to travel approximately 10% nationwide.
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