SIU InvestigatorPrimary Location: Rockville, MD
Additional Locations: MD-Rockville Apply
69336Fundamental Components: Conducts investigations of known or suspected acts of healthcare/disability fraud and abuse* Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases* Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc* Facilitates the recovery of company and customer money lost as a result of fraud matters* Provides input regarding controls for monitoring fraud related issues within the business units* Delivers educational programs designed to promote deterence and detection of fraud and minimize losses to the company* 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 clinical and legal review Documents all appropriate case activity in tracking system Makes referrals, both internal and external, in the required timeframe Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations Exhibits behaviors outlined in Employee Competencies Background Experience: Investigative experience, preferably in the area of healthcare/disability fraud and abuse.Experience in insurance claims investigation or professional/clinical experience, background with law enforcement agencies; or seven years of professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims. College degree in Criminal Justice or a related field. Additional Job Information: Knowledge of Aetna's policies and procedures.Ability to utilize company systems to obtain relevant electronic documentation.Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis.Strong verbal and written communication skills.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. Desired Skills: Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment Functional Skills: Claim - Policies & procedures, General Management - Data analysis & interpretation, Lega - Special investigations Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by 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.
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, a CVS Health Company, 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, a CVS Health Company.Sign Up
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, a CVS Health Company.