SIU Sr. InvestigatorPrimary Location: Kenner, Louisiana
Additional Locations: LA-Kenner Apply
60073Fundamental Components: Conducts more high level, 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 Leader 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 Aetna's approach to fighting fraud* Provides input regarding controls for monitoring fraud related issues within the business units* Background Experience: 3-5 years investigative experience in the area of healthcare/disability fraud and abuse matters.
College degree in Criminal Justice or a related field.
Additional Job Information: Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations fo fraud and abuse.
Knowledge of Aetna's policies and procedures.
Knowledge and understanding of complex clinical issues.
Competent with legal theories.
Strong communication and customer service skills. Ability to effectively interact with different groups of people at different levels in any situation.
Strong analytical and research skills. Proficient in researching information and identifying information resources.
Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
Required Skills: Finance - Managing Aetnas Risk, General Business - Communicating for Impact, Leadership - Driving Change Desired Skills: Finance - Delivering Profit and Performance, General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen Functional Skills: Finance - Audit - fraud prevention, Finance - External audit (Medicare, reimbursement and premiums), Finance - Internal audit, Finance - Internal audit - fraud prevention, detection, investigation, Finance - Internal audit - investigations (background, internal, criminal) Potential Telework Position: No Percent of Travel Required: 10 - 25% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: 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.
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