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Investigator, Special Investigations Unit (SIU) ID-12239

Welcome to Aetna, where we are committed to improving the health and well-being of our members through innovative solutions and exceptional service. We are currently seeking a dedicated and experienced Investigator to join our Special Investigations Unit (SIU). As an Investigator, you will play a crucial role in our efforts to prevent and detect fraud, waste, and abuse within our healthcare system. We are looking for a highly motivated and detail-oriented individual with a strong background in investigations, as well as a passion for making a positive impact on our members' lives. If you have a keen eye for detail, excellent analytical skills, and a passion for uncovering the truth, we encourage you to apply for this exciting opportunity.

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  1. Conduct thorough and detailed investigations of potential fraudulent, wasteful, or abusive activities within the healthcare system.
  2. Utilize various tools and resources to gather evidence and information, such as claims data, medical records, and interviews.
  3. Collaborate with internal departments and external agencies to identify and analyze patterns of potential fraud, waste, and abuse.
  4. Develop and maintain relationships with law enforcement, regulatory agencies, and other industry professionals to stay informed of current trends and best practices.
  5. Prepare accurate and concise written reports detailing investigation findings and recommendations for further action.
  6. Identify potential legal and financial risks and escalate to appropriate parties, such as the SIU manager and legal counsel.
  7. Conduct interviews and obtain statements from involved parties, ensuring adherence to ethical and legal guidelines.
  8. Communicate effectively with Aetna team members, management, and external stakeholders to provide updates on investigations and coordinate efforts.
  9. Conduct research and analysis to support investigations and stay up-to-date on industry regulations and guidelines.
  10. Maintain confidentiality and data privacy while handling sensitive information and documents.
  11. Participate in training and development opportunities to enhance investigative skills and knowledge.
  12. Collaborate with other SIU team members to identify process improvement opportunities and implement effective strategies to prevent and detect fraud, waste, and abuse.
  13. Represent Aetna in a professional and ethical manner at all times.
  14. Adhere to all company policies, procedures, and compliance regulations.
  15. Continuously evaluate and improve investigation processes and procedures to ensure efficiency and effectiveness in preventing and detecting fraud, waste, and abuse.

Job Qualifications
Bachelor's Degree In Criminal Justice, Law Enforcement, Or A Related Field.

Minimum Of 3 Years Experience In Conducting Investigations, Preferably In The Insurance Industry.

Knowledge Of State And Federal Laws Pertaining To Insurance Fraud And Healthcare Fraud.

Strong Analytical Skills And Ability To Gather And Evaluate Evidence.

Excellent Written And Verbal Communication Skills, As Well As The Ability To Present Findings In A Clear And Concise Manner.

Required Skills
Interviewing skills

Analytical Thinking

Report Writing

Medical Terminology

Case management

Fraud detection

Legal Knowledge

Investigative Techniques

Evidence Collection

Research Abilities

Surveillance Tactics

Soft Skills
Communication

Conflict Resolution

Emotional Intelligence

Leadership

Time management

creativity

Teamwork

Active Listening

Adaptability

Problem-Solving

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