Investigator

• Investigate suspected insurance fraud involving auto, property, casualty, workers’ compensation, and other personal, commercial, and specialty lines of business.
• Collaborative with internal stakeholders and external partners to evaluate and investigate suspicious insurance transactions (claims, underwriting, policy, etc.), collect evidence, support fraud detection programs, and communicate investigative findings to internal and external partners, regulators, and law enforcement.
• Support fraud detection and investigation by identifying red flags, gathering facts, and documenting evidence in compliance with company policy and legal requirements.
• Review claim files for basic red flags (inconsistencies, late reporting, coverage anomalies, questionable damages, medical billing issues).
• Apply checklists, referral criteria, and scoring tools to determine whether further investigation is warranted.
• Conduct thorough investigations of suspect insurance claims on moderate to high complexity cases with minimal supervision.
• Meticulous attention to detail to ensure accuracy and thoroughness in investigations and ensure efficient and effective investigations are completed using the most appropriate method of investigation through either field, desktop, or combination thereof.
• Evaluate, coordinate, and recommend investigative action plans in collaboration with claims, underwriting, and legal partners.
• Coordinate and monitor outside vendor activity related to assigned SIU investigations.
• Prepare detailed investigative reports for internal decision-making; support referrals to law enforcement or legal action when necessary, and where applicable to state fraud bureaus.
• Stay informed on regulations and statutes as well as internal protocols and procedures.
• Maintain thorough documentation of investigative actions and work products in accordance with accepted SIU operating standards and best practices.
• Serve as a subject matter expert for claims and/or Underwriting Department training on the detection, deterrence, and prevention of fraud.

Investigator II handling insurance fraud investigations for West Bend

Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia

Investigator II handling insurance fraud investigations for West Bend, focusing on various personal, commercial, and specialty lines. Collaborating with internal stakeholders and external partners to evaluate and investigate suspicious transactions.

• Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud
• Claim reviews for appropriate coding, data mining, entity review, law enforcement referral
• Responsible for identifying and developing enterprise-wide specific healthcare investigations
• Effectively establish rapport and on-going working relationship with law enforcement
• May assist in training of internal and external entities

Investigator II responsible for healthcare fraud investigation and claim reviews

Investigator II

Investigator II investigating healthcare fraud and conducting claim reviews across multiple health plans. Collaborating with law enforcement and assisting in policy development for preventive measures.

• Conduct timely investigations including recorded statements and interviews of claimants, witnesses, and employers.
• Provide timely status updates to case manager and client.
• Timely and clear documentation of the claim files.
• Maintain highest level of confidentiality and professionalism.
• Develop appropriate investigative action plan.
• Ensure accuracy, quality and timeliness of the evidence gathered during an investigation as well as compliance with all applicable laws, legal codes, and governing agencies.
• Provide Claim Adjuster with timely investigation results and document investigative findings.
• Determine whether additional evidence is required including but not limited to accident reports, accident scene reconstructions, witness statements, police reports, expert opinion, etc.
• Provide recommendations and decisions surrounding investigative efforts.
• Perform detailed database queries on SIU investigations to include analysis and organization of critical data to assist during the assigned investigation.
• Be able to evaluate State compliance referrals, as applicable, when questionable or suspicious activity is identified.
• Maintain active membership in professional organizations that provide SIU assistance and resources.
• Establish and maintain relationships with law enforcement, government regulatory agencies and insurance industry personnel assisting when needed or required.

SIU Investigator conducting investigations for Delta Group

SIU Investigator

SIU Investigator conducting investigations for Delta Group focusing on insurance claims, mainly Workers' Compensation. Engaging with clients, law enforcement, and regulatory agencies to identify fraud.

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Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia

Investigator II

SIU Investigator