Conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare and disability 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/disability 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 deterence 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
Investigative experience, preferably in the area of healthcare/disability fraud and abuse.
Experience in insurance claims investigation or professional/clinical experience, background with law enforcement agencies; or seven years of professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims.
College degree in Criminal Justice or a related field preferred
Additional Job Information
Knowledge of Aetna's policies and procedures.Ability to utilize company systems to obtain relevant electronic documentation.Strong customer service skills. Ability to interact with different groups of people at different levels and provide assistance on a timely basis.Strong verbal and written communication skills.Strong analytical and research skills. Proficient in researching information and identifying information resources.Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
Associate's degree or equivalent experience
Percent of Travel Required
10 - 25%
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.