SIU Investigator (Fully Remote)
This position can be work from home anywhere in the United States but must be willing to work an EST/CST schedule.
The SIU Investigator 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.
- Routinely handles 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.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
- Knowledge of Behavioral Health policies and procedures.
- Experience working Behavioral Health fraud cases.
- Experience working on health care fraud, waste, and abuse investigations and audits required.
- Knowledge of CPT/HCPCS/ICD coding.
- Knowledge and understanding of clinical issues.
- Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.
- Strong communication and customer service skills.
- Ability to effectively interact with different groups of people at different levels in any situation.
- Strong analytical and research skills using health care data.
- Proficient in researching information and identifying information resources.
- Ability to utilize company systems to obtain relevant electronic documentation.
- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
- Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
- Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)
- A Bachelor's degree, or an Associate's degree, with an additional three years (4 years total) working on health care fraud, waste, and abuse investigations and audits required.
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