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.

• Conducts investigations into fraud cases
• Coordinates investigative assets and conducts field investigations
• Analyzes fraud schemes and prepares for litigation
• Collaborates with external agencies for documentation gathering
• Provides training and support to other investigators

Investigator handling complex fraud cases for GEICO

Internal Major Case SIU Investigator

Investigator investigating large-scale fraud cases involving multiple jurisdictions for GEICO. Conducting analyses, collaborating with law enforcement, and providing support to other investigators.

• Investigates complaints involving discrimination, harassment, retaliation, sexual misconduct, general misconduct, and other policy violations.
• Conducts impartial, comprehensive investigations in accordance with established procedures, University, and federal requirements.
• Develops case-specific investigative strategy, including identification of issues, evidence, and witnesses.
• Conducts interviews with complainants, respondents, witnesses, and other relevant parties using professional investigative interviewing techniques.
• Navigates and investigates Code of Conduct complaints by engaging with the complainant, witnesses, and/or leadership.
• Works to informally resolve and assist the leader on addressing the situation when appropriate.
• Can serve as a mediator, specifically in Code of Conduct matters, to resolve workplace disputes.
• Collects, reviews, and documents relevant evidence while maintaining objectivity and following all leads.
• Provides case status and procedural updates to complainants, respondents, and leaders as appropriate during the investigation.
• Prepares accurate, thorough, and well-organized investigative reports for review by the Assistant Director, Executive Director, or designated decision-makers.
• Maintains investigative files with discretion, confidentiality, and sound judgment regarding sensitive information.
• Coordinates with the Office of Compliance and Prevention Education, Office of Student Rights and Responsibilities, Office of the General Counsel, Employee Relations, and other relevant offices.
• Assists with Title IX hearing preparation and presents case information clearly and objectively when required.
• Conducts investigations on regional campuses and within the statewide extension system as needed.
• Maintains ongoing professional development to stay current on best practices, policy updates, and applicable legal or procedural requirements.
• Performs other related investigative and conduct-related duties as assigned in support of the Division of Talent and Culture and, as needed, the Office of Student Rights and Responsibilities.

Investigator role for Employee Relations at West Virginia University

Investigator – Talent and Culture

Investigator role for Employee Relations at West Virginia University handling complaints and employee investigations. Collaborate with University leaders to address workplace concerns through conflict resolution and mediation.

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims.
• Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
• Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
• Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
• Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
• Attend and participate in regional FWA Task Force and other state or federal meetings.
• Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
• Ensure regulatory reporting is developed, accurate, and submitted timely.
• Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
• Develop and conduct internal FWA related training.
• Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
• Present and discuss case findings and recommendations in case review meetings with department and company management.
• Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
• Coordinate and manage the production of investigative materials in support of settlement negotiations.

Senior Investigator managing healthcare fraud investigations at PacificSource.

Senior Investigator

Senior Investigator managing healthcare fraud investigations and compliance at PacificSource. Leading audit activities across dedicated teams and ensuring regulatory adherence.

• Receives, evaluates and responds to inquiries and requests for information related to all forms of illegal harassment, discrimination, or misconduct in the WVU system
• Conducts thorough and professional investigations, including contacting and scheduling witnesses, following through on all leads and maintaining objectivity
• Prepares and composes accurate investigation reports, with limited errors, for presentation and review by the Director/Executive Director
• Maintains a collaborative relationship with relevant offices, including the Office of Equity Assurance, the Department of Public Safety, and the Office of the General Counsel
• Serves as a resource to regional campuses and conducts investigations on those campuses as needed
• Maintains a timely professional development program relevant to the responsibilities of the position
• Presents case information accurately and articulately at hearings when called upon
• Assists in other duties relevant to the work of Employee Relations and/or Student Conduct as assigned

Internal Investigator handling cases of discrimination and misconduct at WVU

Internal Investigator – Office of Student Rights & Responsibilities

Internal Investigator at West Virginia University conducting investigations into discrimination and misconduct cases. Ensuring compliance with federal, state, and University mandates regarding student and employee rights.

• Conduct background research to identify relevant information regarding individuals, organizations, or entities under review.
• Conduct investigations involving potential fraud, waste, and abuse.
• Analyze healthcare and operational data to identify trends, anomalies, and potential indicators of fraud.
• Review applicable laws, regulations, policies, and guidance to support investigative activities.
• Collect, review, and analyze records and documentation relevant to investigations.
• Conduct interviews and maintain accountability for evidentiary materials in accordance with established procedures.
• Document investigative findings and prepare clear, well-supported reports and recommendations.
• Coordinate with internal staff, legal counsel, government stakeholders, and law enforcement agencies, as appropriate.
• Collaborate with investigators, analysts, program managers, and subject matter experts to develop investigative strategies and resolve cases.
• Enter and maintain investigative information in case management and tracking systems.
• Present investigative findings and recommendations to management and clients.
• Assist with identifying emerging fraud schemes and recommending new investigative priorities.
• Prepare recurring and ad hoc reports regarding investigative activities and case status.
• Meet established quality standards and project deadlines.

Senior Investigator conducting healthcare fraud investigations at Integrity Management Services

Senior Investigator conducting investigations for healthcare program integrity initiatives, analyzing potential fraud and collaborating with various stakeholders.

• The investigator will generate new investigations, and to continue with ongoing investigation and civil actions involving fraud in areas such as healthcare, contracting, and grants, as well as other fraud and abuse of federal public funds and programs.
• Regularly meets with the ACE attorneys and with designated agency personnel for the purpose of generating fraud investigations.
• Performs a variety of ancillary investigations-related services in direct support of any assigned fraud
• Utilizes electronic databases such as public records, property records, business records, and other government-maintained databases, to identify documents, witnesses and other physical evidence.
• Prepares reports on progress of investigations for use by AUSAs and supervisory attorneys. These reports may include significant findings and conclusions, analyses of information located in electronic databases, presentations, recommendations for additional investigative actions and candid assessments of strengths and weaknesses of witnesses, documentary evidence, or other aspects of a case.
• Examines books, ledgers, payrolls, cost reports, billing statements, invoices, correspondence, computer data, and other records pertaining to the transactions, events, or allegations under investigation.
• Performs sophisticated analyses of large-scale hard-copy and electronic data, such as health care claims data, financial transaction data, accounting records, or bank records to develop investigative leads and to determine their potential relevance to the allegations at issue.
• Gathers and analyzes facts including witness statements, timelines, and scientific or technical data for the purpose of advancing investigative objectives. Establishes and verifies relationships between facts and evidence obtained or presented to confirm authenticity of documents, to corroborate witness statements, and to otherwise build proof necessary for successful litigation or settlement.
• Develops and analyzes evidence and collects information relating to such evidence, or other legal matters under consideration, from appropriate primary and secondary sources. Performs analysis to clarify the target suspect's or organization's pattern of operations, to identify information relevant to the legal issues involved, and to recommend valuable approaches to the AUSAs or other members of the investigative team. Develops and refines proof required to assist in determining legal responsibility for violations.
• Assists ACE AUSAs with in-person and/or telephonic interviews of witnesses, depositions, and sworn witness examinations.
• Assists with the preparation and service of subpoenas for documentary materials, interrogatory answers, or witness testimony in connection with ACE investigations.
• Develops an understanding of all applicable federal, state, or local laws to the extent necessary to make sound decisions on direction and scope of investigations. Determines proof required to affix responsibility for violations, and devise methods for obtaining, preserving, and presenting evidence to the greatest effect.
• Assists with determining the most efficacious methods for planning, scheduling, and conducting investigations, and identifies any resources that may be required.
• Performs other related ACE investigator duties as assigned and within scope.
• Attends meetings and trainings as may be required and appropriate.

ACE Investigator supporting federal agency fraud detection and investigations

Civil Enforcement Investigator

ACE Investigator supporting government innovation through fraud detection and investigations. Joining a team dedicated to solving dynamic government challenges with technology.

• The investigator will generate new investigations, and to continue with ongoing investigation and civil actions involving fraud in areas such as healthcare, contracting, and grants, as well as other fraud and abuse of federal public funds and programs.
• Regularly meets with the ACE attorneys and with designated agency personnel for the purpose of generating fraud investigations.
• Performs a variety of ancillary investigations-related services in direct support of any assigned fraud.
• Utilizes electronic databases such as public records, property records, business records, and other government-maintained databases, to identify documents, witnesses and other physical evidence.
• Prepares reports on progress of investigations for use by AUSAs and supervisory attorneys. These reports may include significant findings and conclusions, analyses of information located in electronic databases, presentations, recommendations for additional investigative actions and candid assessments of strengths and weaknesses of witnesses, documentary evidence, or other aspects of a case.
• Examines books, ledgers, payrolls, cost reports, billing statements, invoices, correspondence, computer data, and other records pertaining to the transactions, events, or allegations under investigation.
• Performs sophisticated analyses of large-scale hard-copy and electronic data, such as health care claims data, financial transaction data, accounting records, or bank records to develop investigative leads and to determine their potential relevance to the allegations at issue.
• Gathers and analyzes facts including witness statements, timelines, and scientific or technical data for the purpose of advancing investigative objectives. Establishes and verifies relationships between facts and evidence obtained or presented to confirm authenticity of documents, to corroborate witness statements, and to otherwise build proof necessary for successful litigation or settlement.
• Develops and analyzes evidence and collects information relating to such evidence, or other legal matters under consideration, from appropriate primary and secondary sources. Performs analysis to clarify the target suspect's or organization's pattern of operations, to identify information relevant to the legal issues involved, and to recommend valuable approaches to the AUSAs or other members of the investigative team. Develops and refines proof required to assist in determining legal responsibility for violations.
• Assists ACE AUSAs with in-person and/or telephonic interviews of witnesses, depositions, and sworn witness examinations.
• Assists with the preparation and service of subpoenas for documentary materials, interrogatory answers, or witness testimony in connection with ACE investigations.
• Develops an understanding of all applicable federal, state, or local laws to the extent necessary to make sound decisions on direction and scope of investigations. Determines proof required to affix responsibility for violations, and devise methods for obtaining, preserving, and presenting evidence to the greatest effect.
• Assists with determining the most efficacious methods for planning, scheduling, and conducting investigations, and identifies any resources that may be required.
• Performs other related ACE investigator duties as assigned and within scope.
• Attends meetings and trainings as may be required and appropriate.

ACE Investigator providing fraud detection support for federal agency initiatives

ACE Investigator with skills in fraud detection and investigation within federal government projects. Collaborating with ACE attorneys to ensure compliance and facilitate investigations.

Investigator jobs in Virginia

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

Internal Major Case SIU Investigator

Investigator – Talent and Culture

Senior Investigator

Internal Investigator – Office of Student Rights & Responsibilities

Senior Investigator

Civil Enforcement Investigator

Civil Enforcement Investigator