Fraud Investigator - 56987BRPrimary Location: Farnborough, United Kingdom
Additional Locations: HANTS-Farnborough Apply
Aetna are a leading diversified health care benefits company, serving an estimated 44 million people.We offer industry-leading information, tools and resources to help people achieve their best possible health.
Aetna’s global business, Aetna International, is one of the world’s largest and most prominent providers, with more than 650,000 members worldwide and a direct settlement network of over 125,000 hospitals and clinics.
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare across the globe. 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.
As well as some excellent benefits and a fantastic working environment, we will give you the space to grow and provide you with opportunities to learn new skills to keep you developing personally and professionally.
Join us and help turn health ambitions into achievements.
We have a great new opportunity for an experienced insurance professional to join our Special Investigations Unit as a Fraud Investigator. In this important role, you will be responsible for the prevention, detection and investigation of known or suspected acts of fraud, violations of Aetna policy, and acts of a criminal or civil nature involving Aetna’s operations.
As the Fraud Investigator you will need to demonstrate a high-level of independence in case investigation and resolution and may mentor less experienced investigators. With the support and direction of the Lead Fraud Investigator & ISIU Manager, you will analyse, develop and successfully complete and resolve high-profile health care fraud investigations, present findings to health care providers and negotiate resolution of issues.
·Investigate cases of potential fraud and abuse, including data analysis, document review, and witness interviews.
·Develop and deliver full data analysis capability to support fraud investigation across claims and other operational areas.
·Produce and maintain fraud MI as required by the business/group or as directed by the Lead Investigator & ISIU Manager.
·Engage and present to Fraud Champions on a regular basis.
·Prepare clear concise investigatory reports to support findings regarding potential fraud, waste or abuse.
·Review information contained in standard claims processing system files (e.g., claims history, provider files) to detect potential fraudulent or abusive billing practices or vulnerabilities in policy and initiate appropriate action.
·Under direction present findings regarding overpayments to providers.
·Under direction of the Lead Fraud Investigator & ISIU Manager (ISIU) work with account managers (with legal and compliance approval) to escalate findings to Plan Sponsors.
·With support from the Lead Fraud Investigator & ISIU Manager (ISIU) prepare cases for referral to law enforcement officials for criminal prosecution or to the relevant licensing boards.
Experience and qualifications required
·Strong working knowledge of health insurance claims and coding.
·Analytical thinking skills.
·Excellent written and oral communication skills.
·Strong organisational and prioritisation skills with ability to manage multiple priorities effectively.
·Ability to use computer software to analyse data.
·Ability to effectively collaborate with key business areas.
·An understanding of market practices in areas affecting the role.
·An understanding of industry fraud activity and best practice.
·Strong sense of initiative and drive and the willingness to self-start activities.
·Ability to build relationships between teams within the business.
·Strong communications/interpersonal skills including negotiation and influencing skills.
·Report writing skills.
·Ability to deliver projects on specific subjects
·Investigative experience, preferably in a position involving healthcare related fraud and/or currently undertaking a formal recognised qualification in Compliance and Counter Fraud would be highly desirable
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.