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 insured's, providers, claimants, customer members, etc.
- Facilitates the recovery of company and customer 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 to the company
- 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
- Exhibits behaviors outlined in Employee Competencies
- Must hold credentials such as a certification from the Association of Certified Fraud Examiners, an accreditation from the National Health Care Anti-Fraud Association, or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
- 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
- 1-3 years Healthcare Insurance Experience
- 1-3 years Medicaid or Medicare Experience
- 1-3 years Healthcare Fraud Investigation Experience
- 1-3 years' Experience dealing with Law Enforcement
- Advanced knowledge of Excel; Excellent communication Skills; Excellent Analytical Skills
- College degree in Criminal Justice or a related field
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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