Supvr, Spec Investigation

Job Description

POSITION SUMMARY

Leads a team comprised of Investigators, Analysts, and Nurses responsible for effectively pursuing the prevention, investigation and prosecution of healthcare fraud, waste, and abuse, recovering funds lost to fraud, waste, and abuse, funds, and complying with state and federal mandates pertaining to the reporting of suspected fraud.

Fundamental Components:

Leads a team of investigators in the planning and execution of investigations of suspected healthcare fraud, waste, and abuse by providers, members, and others. Provides direction and counsel to investigators on their team, on the handling of cases, and facilitates issue resolution. Assists investigators in identifying resources and best course of action to take in a timely and effective manner. Conducts case reviews, from Investigators on their team, and provides feedback to Investigators on completeness and quality of the investigation. Conducts team member evaluations and provides performance feedback to staff on an ongoing basis. Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match Investigators' current skills and development needs. Assesses training needs and works with their staff on development plans for Investigators. Develops and maintains close working relationships with federal, state, and local law enforcement agencies in the investigation and prosecution of acts of healthcare fraud, waste, and abuse. Responsible for overall monitoring and progress of cases, keeping in mind issues like statutes of limitations and specific state and federal mandates.

BACKGROUND/EXPERIENCE desired:

5+ years claims investigative experience, preferably in the area of healthcare/disability fraud and abuse.

Supervisory experience preferred

Certified Professional Coder (CPC) designation preferred

EDUCATION

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

Medical Management/Certified Coding Specialist is desired

Medical Management/Certified Coding Specialist-Physicians (CCS-P) is desired

FUNCTIONAL EXPERIENCES

Functional - Legal/Compliance - investigation/4-6 Years

Functional - Information Management/Business information analysis/4-6 Years

Functional - Risk Management/Insurance, finance and loss control/4-6 Years

Functional - General Management/Process & quality improvement/1-3 Years

Functional - Legal/Special investigations/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/Power User

Technical - Desktop Tools/Microsoft Word/4-6 Years/Power User

Technical - Operating Systems/Windows/4-6 Years/Power User

REQUIRED SKILLS

Leadership/Collaborating for Results/ADVANCED

Leadership/Driving Change/ADVANCED

Finance/Managing Aetnas Risk/ADVANCED

DESIRED SKILLS

Leadership/Creating Accountability/ADVANCED

General Business/Demonstrating Business and Industry Acumen/ADVANCED

Leadership/Driving a Culture of Compliance/MASTERY

Telework Specifications:

Considered for any US location; training period in the office may be required

ADDITIONAL JOB INFORMATION

Strong analytical and research skills. Proficient in researching information and identifying information resources. Able 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. Strong leadership and communication skills. Knowledge of the multifaceted healthcare industry and how it operates. General knowledge of healthcare industry policies and procedures.

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. Click here to review the benefits associated with this position.

Aetna takes our candidates'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.