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SIU Sr Investigator - NY Health Plan (57757BR)

Primary Location: New York, New York
Additional Locations: NY-New York
Aetna Better Health of NY is hiring a Sr SIU Investigator to support our growing NY Health Plan.

Our Sr SIU Investigator will conduct more high level, complex 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

This position is part time office based and part time telework in NY.

Fundamental 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.

(*) Preferred applicants will have current or prior experience working specifically in the NY Medicare/ Medicare field
(*) Excellent verbal and written communication skills
(*) Excel skills
(*) Presentation skills to various audiences including upper management

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.

Potential Telework Position:

Percent of Travel Required:
0 - 10%

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


Click To Review Our Benefits (PDF)


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