KS MCD Special Investigations Unit Sr Investigator (51679BR)
Overland Park, KS
Conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.
Conducts investigations of known or suspected acts of healthcare fraud 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 claims committed by members, providers, etc* • Facilitates the recovery of money lost as a result of fraud matters* • Provides input regarding controls for monitoring fraud related issues within the business units* • Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses * • Maintains open communication with constituents within and external to the company* • Uses available resources and technology in developing evidence, supporting allegations of fraud 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 • Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.
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. • Knowledge of Aetna's policies and procedures
3-5 years Healthcare Insurance Experience - Clinical Experience a plus; 3-5 years Medicaid and Medicare Experience; 3-5 years Healthcare Fraud investigations; 3-5 years' experience dealing with Law Enforcement/Government Agencies; Advanced knowledge of Excel; Excellent communication Skills; Excellent Analytical Skills
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Risk Management/Investigative services/4-6 Years
Risk Management/Insurance, finance and loss control/4-6 Years
Legal/Special investigations/4-6 Years
Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Desktop Tools/Microsoft Word/4-6 Years/End User
Desktop Tools/Microsoft SharePoint/4-6 Years/End User
Desktop Tools/Microsoft Outlook/4-6 Years/End User
Finance/Managing Aetna's Risk/ADVANCED
General Business/Communicating for Impact/MASTERY
General Business/Turning Data into Information/ADVANCED
General Business/Demonstrating Business and Industry Acumen/ADVANCED
Leadership/Collaborating for Results/ADVANCED
Leadership/Driving a Culture of Compliance/MASTERY
ADDITIONAL JOB INFORMATION
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to improving the lives of Kansas KanCare members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way.
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position.
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.