Aetna SIU Investigator in Hartford, Connecticut
Req ID: 50637BR
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 comprehensive analysis of claim utilization Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc. Assists with data mining activities using available tools and applications Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases 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, supporting allegations of fraud and abuse Researches and prepares cases for 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
1-3 years of experience in the area of healthcare fraud, waste and abuse investigations 1-3 years of experience with healthcare data interpretation and analysis strong verbal and written communication skills Strong analytical and research skills Proficient in researching information and identifying information resources 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 AHFI certification and/or CPC a plus
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Functional - Claims/Policies & procedures/1-3 Years
Functional - Claims/Claim processing - Medical or Hospital - ACAS/1-3 Years
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
Functional - Legal/Special investigations/1-3 Years
Technical - Remote Access/Broadband VPN/1-3 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Communicating for Impact/ADVANCED
General Business/Turning Data into Information/ADVANCED
Leadership/Collaborating for Results/FOUNDATION
Telework / WAH opportunity depending on candidate. If selected condition resides around CT office, opportunity for Part time telework, otherwise WAH opportunity
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
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.