As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.
- Conducts more high level, complex investigations of known or suspected acts of healthcare fraud and abuse. Routinely handles cases that are sensitive or high profile, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.
- 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.
- Makes referrals, both internal and external, in the required timeframe.
- Facilitates the recovery of company and customer money lost as a result of fraud matters.
- Provides guidance for less experienced or skilled Investigators. Assists Investigators in identifying resources and best course of action on investigations.
- Serves as back up to the manager as necessary.
- 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.
- Minimum three (3) years working on health care fraud, waste, and abuse investigations and audits required.
- Knowledge of Ohio Medicaid policies and procedures.
- Knowledge of CPT/HCPCS/ICD coding.
- Knowledge and understanding of complex clinical issues.
- 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. 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.
- Must be able to travel in-state up 10-25% of the time with personal vehicle. Must possess reliable transportation, active/valid driver’s license, and proof of vehicle insurance.
Vacancy Type: Full Time
Job Location: Columbus, OH, US
Application Deadline: N/A