Senior Investigator, Special Investigations Unit (Aetna SIU)
About The Position
Conducts high level, complex analysis of Dental Providers and Practices to effectively pursue the prevention, investigation and prosecution of Fraud, Waste and Abuse. Collaboration with Dental Network, providing meaningful evidence of Fraud, Waste and Abuse to support corrective action. Routinely handles cases that are sensitive or high profile, those that are national in scope. Investigates to prevent payment of fraudulent activities. Researches and prepares cases for clinical, legal and leadership review. Documents all appropriate case activity in case tracking system. Makes referrals, both internal and external, in the required timeframe. Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution. Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings. Gives presentations to internal and external customers regarding Dental matters. Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units. Maintains open communication with constituents within and external to the company.
Requirements
- 3-5 years of healthcare fraud investigations experience
- Experience with Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research
- Ability to travel for business purposes and legal proceedings
- Proficient in data analysis and research
- Knowledge of Medical Terminology
Nice To Haves
- Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI)
- Bilingual in English/Spanish
- Strong verbal and written communication skills.
- Strong customer service skills.
- Knowledge of Aetna's policies and procedures
- Ability to interact with different groups of people at different levels.
- Ability to utilize company systems to obtain relevant electronic documentation.
- Clinical or FWA Dental experience
Responsibilities
- Conducts high level, complex analysis of Dental Providers and Practices to effectively pursue the prevention, investigation and prosecution of Fraud, Waste and Abuse.
- Collaborates with Dental Network, providing meaningful evidence of Fraud, Waste and Abuse to support corrective action.
- Routinely handles cases that are sensitive or high profile, those that are national in scope.
- Investigates to prevent payment of fraudulent activities.
- Researches and prepares cases for clinical, legal and leadership review.
- Documents all appropriate case activity in case tracking system.
- Makes referrals, both internal and external, in the required timeframe.
- Communicates and cooperates with federal, state, and local law enforcement agencies to assist in the investigation and prosecution.
- Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings.
- Gives presentations to internal and external customers regarding Dental matters.
- Provides input regarding controls for monitoring Fraud, Waste and Abuse related issues within the business units.
- Maintains open communication with constituents within and external to the company.
Benefits
- medical coverage
- dental coverage
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
