Investigator, Special Investigations Unit (Aetna SIU)

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Requirements:

• 1-3 years of Investigative experience in healthcare fraud, waste, and abuse.
• Strong knowledge of medical terminology/CPT/HCPCS coding.
• Advanced skills with Microsoft Excel.
• Experience in healthcare/medical insurance claims investigation or professional/clinical experience.
• Proficient in researching information and identifying information resources.
• Proficiency in Word, MS Outlook products, Database search tools, and internet research.
• Ability to interact with different groups of people and provide assistance in a timely basis.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings.

Responsibilities:

• Investigates to prevent payment of fraudulent claims submitted to the Medicaid lines of business.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in case tracking system.
• Facilitates feedback with providers related to clinical findings.
• Initiates proactive data mining to identify aberrant billing patterns.
• 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 guidance for less experienced 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 investigations.
• Demonstrates high level of knowledge and expertise during civil and criminal proceedings.
• Gives presentations to customers regarding healthcare fraud matters.