Job Description
Job Description
Conducts investigations of known or suspected acts of healthcare fraud, waste, 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, abusive, or otherwise improperly billed claims submitted by providers, members, and others - Facilitates the recovery of company and customer monetary losses * Provides input regarding controls for preventing or monitoring fraud related issues within the business units - Delivers educational programs designed to promote deterrence 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, waste, 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 - Exhibits behaviors outlined in Employee Competencies - Exhibits behaviors outlined in SIU Investigator Competencies
This role can be considered WFH-US.
Required Qualifications
3-5 years investigative experience in the area of healthcare fraud and abuse matters.
- Strong analytical and research skills. Proficient in researching information and identifying information resources.
- Strong verbal and written communication skills.
- Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
- Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
- Ability to utilize company systems to obtain relevant electronic documentation.
Preferred Qualifications
-Knowledge of Aetna's policies and procedures is an asset but not required.
-Prior claims investigations experience preferred
Education
Bachelors degree in Criminal Justice or equivalent experience. Other desired credentials include nurse professionals, law enforcement experience, Certified Professional Coders (CPC), Accredited Health Care Fraud Investigators (AHFI), and/or Certified Fraud Examiners (CFE).
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
Conducts investigations of known or suspected acts of healthcare fraud, waste, 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, abusive, or otherwise improperly billed claims submitted by providers, members, and others - Facilitates the recovery of company and customer monetary losses * Provides input regarding controls for preventing or monitoring fraud related issues within the business units - Delivers educational programs designed to promote deterrence 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, waste, 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 - Exhibits behaviors outlined in Employee Competencies - Exhibits behaviors outlined in SIU Investigator Competencies
This role can be considered WFH-US.
Required Qualifications
3-5 years investigative experience in the area of healthcare fraud and abuse matters.
- Strong analytical and research skills. Proficient in researching information and identifying information resources.
- Strong verbal and written communication skills.
- Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
- Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
- Ability to utilize company systems to obtain relevant electronic documentation.
Preferred Qualifications
-Knowledge of Aetna's policies and procedures is an asset but not required.
-Prior claims investigations experience preferred
Education
Bachelors degree in Criminal Justice or equivalent experience. Other desired credentials include nurse professionals, law enforcement experience, Certified Professional Coders (CPC), Accredited Health Care Fraud Investigators (AHFI), and/or Certified Fraud Examiners (CFE).
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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