Senior Investigator, Special Investigations Unit (Aetna SIU)
Core
Conduct high-level, complex investigations of known or suspected healthcare fraud and abuse, including national scope cases and intricate billing schemes.
Role type
Senior IC healthcare fraud investigator
Builds
Recovered company and customer monies lost from aberrant billing
Domain
Healthcare / Insurance / Fraud Investigation
Deliverable
client delivery
Required skills
Healthcare fraud investigation, Medical coding (CPT, HCPCS, ICD10), Data analysis (claims data), Microsoft Excel (pivot tables, Power BI), Regulatory compliance, Witness testimony
Preferred skills
Medicaid/Medicare investigation experience, Independent judgement, Clinical issue analysis, Fraud examination credentials (CFE/AHFI)
Technologies
SIU Tools, Microsoft Office, Power BI
Responsibilities
Investigate program integrity to prevent aberrant Medicaid claims payment, Conduct research on subjects and entities, Initiate proactive data mining to identify billing patterns, Analyze claims data for aberrancy, Prepare cases for clinical and legal review, Collaborate with Medical Directors and law enforcement, Provide training to junior investigators, Testify in civil and criminal proceedings
Seniority
Senior, hands-on IC with mentorship responsibilities