Aetna Director, Special Investigation in Philadelphia, Pennsylvania

Req ID: 55743BR

POSITION SUMMARY

The SIU Director position will oversee multiple investigative teams responsible for all healthcare fraud investigation types (provider, pharmacy, member, etc.) across multiple lines of business. This position will report directly to Aetna's Sr. Director of Special Investigations.

Fundamental Components:

Leads and directs the operational activities, budgetary, and financial responsibilities of staff across multiple teams responsible for preventing, detecting, investigating, correcting and reporting healthcare fraud, waste, and abuse. Participates in the development and execution of strategic and operational goals and initiatives based on departmental and enterprise goals and objectives. Makes strategic and operational business decisions by identifying and analyzing trends and improvement opportunities through the effective use of resources, tools, and metrics. Maintains a thorough understanding of healthcare fraud, waste, and abuse and identifies instances where the company may be at risk. Provides direction to staff on the handling of complex cases and facilitates issue resolution. Ensures associates are performing in compliance with company policy, contract provisions, fiduciary responsibilities, and applicable state/federal laws and regulations. Responsible for the ongoing management of staff by attracting talent, setting direction, providing appropriate guidance, effectively managing performance, recognizing contributions, and developing talent/capabilities. Maintains transparent communication by appropriately communicating organization information through department meetings, one-on-one meetings, email and regular interpersonal communication. Ensures quality by establishing and overseeing best practices, and ensuring the development and delivery of training as needed. Maintains and shares industry knowledge by keeping current on laws, trends, and issues. Directs and evaluates investigation strategies that respond to changes in law, technology, and company policy. Serves as primary contact for outside law enforcement agencies (local, state, federal). Coordinates joint investigations that require law enforcement intervention. Represents the company at fraud related industry meetings, associations, and events.

BACKGROUND/EXPERIENCE desired:

10+ years supervisory experience. Minimum of ten (10) years of combined experience conducting, managing, or directing investigations in the area of insurance fraud, law enforcement, civil or criminal litigation, or similar field. Healthcare insurance Fraud working across multiple product line experience needed. Demonstrated ability to effectively lead, coach and develop investigative staff. Technical and business management acumen; advanced claims investigations and resolution skills; advanced knowledge of insurance and claims handling principles, practices, and procedures. Excellent communication, negotiation, and presentation skills with the ability to effectively interact with internal and external business partners at all levels. Excellent analytical and problem solving skills, with the ability to simultaneously manage multiple projects and teams. Ability to deal effectively with ambiguous situations and issues. Creative thinker; embraces diverse and innovative ideas to solve problems. Proven ability to achieve results by taking a proactive long-term view of business goals and objectives. Helps others to excel through collaboration and building strong relationships. Raises expectations of self and others by continuously learning and broadening industry and technical skills. Professional certification, accreditation, or designation related to fraud investigations also desired (e.g. AHFI, CFE).

EDUCATION

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

Telework Specifications:

Considered for any US location; training period in the office may be required

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 candidates'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.