Responsibilities
- Use specialized services to identify new and emerging fraud trends and provide an enhanced focus on complex claims, high-risk claim exposures, such as organized crime-rings, Complex Financial Fraud Schemes, medical provider treatment fraud, medical provider billing fraud, Corporate Investigations, Case File Reviews, Anti-Fraud Consulting, and Criminal Conspiracies involving the insurance industry.
- Conduct complex Investigations across all lines of business in the insurance industry which may involve serious injuries, extensive damages, large scale or multi-party construction defect matters or complicated coverage issues.
- Analyze and interpret complex and voluminous evidence and convey highly technical information effectively to others.
- Prepare and submit detailed investigative reports as necessary and make investigative recommendations in accordance with all applicable fraud statutes, case law, and the policy contracts.
- Assist clients as a subject matter expert/ expert witness, coordinate and attend Examinations Under Oaths, and attend legal proceedings as required.
- Utilize the most advanced investigative techniques in the industry to include Analytics; Link Analysis; and Advanced Database and Social Media Analysis to assess suspected fraudulent claims or provider activity and create business intelligence reports that advance fraud identification and prevention efforts.
- Coordinate with local, state, and federal law enforcement and prosecutors, Department of Insurances, NICB, other carrier SIU’s.
- Independently develop a strategic plan to achieve assignment objectives, ensuring thorough documentation and effective communication with clients and their Special Investigation Unit Supervisor
Requirements
- Extensive knowledge of Insurance policies and the components of fraud
- Ability to determine if claims warrant reporting to the appropriate state agency for prosecution
- Ability to analyze and interpret complex and voluminous evidence
- Ability to convey highly technical information effectively to others
- Proficiency in using advanced investigative techniques including Analytics, Link Analysis, and Advanced Database and Social Media Analysis
