Job Description

Overview

Conducts investigations to effectively pursue the prevention, investigation and prosecution of insurance fraud and abuse; to recover lost funds; and to comply with state regulations mandating fraud plans and practices.

Job Duties:

• Conducts investigations of known or suspected acts of fraud and abuse.
• Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to fraud cases.
• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc.
• Facilitates the recovery of the company and customer money lost because of fraud matters.
• 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.
• Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.

Required Qualifications:

• Strong background in insurance fraud investigations.
• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.
• Consistent demonstration of accuracy, thoroughness and timeliness in completing work assignments; detail oriented.
• 5 + years’ SIU experience with an insurance carrier is required.
• Strong customer service skills.
• Ability to multitask at a high level.
• Computer savvy with 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.

Preferred Qualifications

• Ability to communicate in English and Spanish.
• Claims handling experience.
• Strong background in Bodily Injury claims investigations.
• 3+ years of experience in Investigations with a Law Enforcement Agency.

Education

• College degree in Criminal Justice or a related field, or a minimum of 8 years in law enforcement or insurance.

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