Special Investigation Unit Lead Review Analyst

Job Description: • The Special Investigations Unit (SIU) is looking for an analytically driven individual who is skilled at identifying outliers through data extraction and analysis • The lead reviewer is accountable for the validation of existing Fraud, Waste and Abuse business rules/leads designed to detect aberrant billing patterns as reviewing incoming referrals • Research and ad hoc report development to identify fraud, waste and abuse schemes and trends • Review company clinical & payment policies to determine the impact of the scheme on Aetna business • Identify all possible issues related to fraud, waste and abuse when reviewing a new lead or referral • Keep current with new & emerging fraud, waste and abuse schemes and trends through training sessions and industry resources • Interpret, analyze and present key findings to internal customers (project team, investigators) providing recommendations based on analytical findings Requirements: • 3-5 years of data interpretation and analysis experience • Healthcare background • Excellent verbal and written communication skills • Experience with healthcare coding • Must be able to travel to provide testimony if needed • Advanced experience with Excel • A solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/ICD/NDC), Aetna clinical and payment policies, as well as core Aetna systems (QNXT, ACAS, EWM, EPDB, IOP) • Some experience using Tableau is a plus • Previous healthcare fraud experience • Experience with Aetna clinical and payment policies • Certified Professional Coder (CPC) certification is a plus • Medicaid Experience Benefits: • Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility