Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment
Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
Researches and prepares cases for clinical and legal review.
Documents all appropriate case activity in case tracking system.
Prepares and presents referrals, both internal and external, in the required timeframe.
Facilitates the recovery of company lost as a result of fraud matters.
Assists team in identifying resources and best course of action on investigations.
Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
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 healthcare fraud matters and Aetna's approach to fighting fraud.
Provides input regarding controls for monitoring fraud related issues within the business units.
Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse

Must reside in Florida.
3 years working on health care fraud, waste, and abuse investigatory and audits required.
Knowledge of CPT/HCPCS/ICD coding
Knowledge and understanding of clinical issues.
Experience and proficiency in Microsoft Word, Excel, and Outlook, Database search tools, and use in the Intranet/Internet to research information.
Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Ability to travel to provider offices within the state of Florida on a monthly basis

Senior Investigator, Special Investigations Unit

About this role