Description: Conducts 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
Fundamental 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. Experience with the WV Medicaid program preferred
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.
Required Skills: General Business - Applying Reasoned Judgment, Leadership - Driving a Culture of Compliance
Functional Skills: Lega - Compliance - investigation
Potential Telework Position: No
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.
Internal Number: 64978BR
About Aetna, a CVS Health Company
Aetna, a CVS Health Company's, mission is to build a healthier world by helping people realize their ambitions and achieve their goals, one person and one community at a time. We are a leading diversified health care benefits company that is helping to transform health care by providing and advancing the information, tools and resources people need to achieve their best possible health.Our team of nearly 50,000 employees serves an estimated 37 million people and is committed to giving them a better health care experience while providing access to affordable, high-quality health care. Our digital tools and online resources help guide members on their health care journey. And our people are empowered, innovative and supported at every step of their own career journey. Our strength as a company enables us to deliver greater value and well-being opportunities to consumers, and bigger challenges, rewards and career opportunities for our employees. Join us and help turn health ambitions into achievements - big and small.