Req ID: 64978BR Job Description 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 Fundamental Components included but are not limited to: 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 Qualifications Requirements and Preferences: 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. Experience with the WV Medicaid program preferred Functional Skills: Lega - Compliance - investigation Required Skills: General Business - Applying Reasoned Judgment, Leadership - Driving a Culture of Compliance 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. Benefit Eligibility Benefit eligibility may vary by position. Job Function: Legal Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.