Senior Investigator, Special Investigations Unit (Aetna SIU)
Core
Conduct high-level, complex investigations of known or suspected healthcare fraud and abuse, specifically targeting Medicaid lines of business to prevent fraudulent claim payments.
Role type
Senior IC healthcare fraud investigator
Builds
Case files for clinical and legal review; data mining reports on aberrant billing patterns; referrals to law enforcement; recovery of lost funds.
Domain
Healthcare / Insurance Fraud
Required skills
Healthcare fraud investigation, Medical coding (CPT, HCPCS, ICD10), Advanced Excel (pivot tables), Data mining, Legal theory knowledge, Clinical issue understanding
Preferred skills
CFE certification, AHFI accreditation, Medicaid/Medicare investigatory experience, Independent judgement, Complex clinical knowledge
Technologies
Microsoft Office (Excel), Case tracking systems
Responsibilities
Investigate suspected healthcare fraud and abuse; Research and prepare cases for clinical and legal review; Document case activity in tracking systems; Facilitate feedback with providers; Initiate proactive data mining to identify aberrant billing patterns; Make internal and external referrals; Facilitate recovery of lost funds; Provide on-the-job training to new investigators; Cooperate with federal, state, and local law enforcement; Provide testimony in civil and criminal proceedings; Give presentations on healthcare fraud matters.
Seniority
Senior, hands-on IC
