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Special Investigation Unit, Senior Investigator (Fully Remote)

Aetna Inc.

This is a Contract position in Las Vegas, NV posted April 9, 2022.

Job Description This position does not require the candidate to live in Michigan but there will be annual travel to Michigan.

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 and deconflictions, 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 Required Qualifications Minimum three years in healthcare field working in fraud, waste and abuse investigations and audits.

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 COVID Requirements COVID-19 Vaccination Requirement CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment.

Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications Located in the Michigan area.

If not located in Michigan, must be willing to travel to Michigan.

Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI) Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA) Knowledge of CPT/HCPCS/ICD10 coding Experience with Medicaid/Medicare Knowledge of Aetna’s Medicaid policies and procedures is a plus Education Bachelor’s degree, or Associates’ degree with additional three years of healthcare fraud investigation experience.

Business Overview 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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