Job Title: Special Investigations Unit Lead (SIU Lead)
Under general supervision, the SIU Lead conducts data analysis of outlier claims activity, reviews fraud referrals from the LifeCare Claims team, investigates instances of suspected fraud, drafts investigative summaries for review by the director of litigation, develops and provides fraud training to the organization, develops fraud reports for submission by client companies, and coordinates case management with outside counsel on fraud matters as well as with state department of insurance investigators on referred suspected fraud matters.
- Manages an investigative caseload of suspected fraud cases under the supervision of the Litigation Director and General Counsel and updates the Company fraud plan.
- Works with outside vendors in the coordination of surveillance, interviews, independent medical review, and background searches in matters involving suspected fraud.
- Analyzes policy files including but not limited to underwriting, policy administration, and claims documents, when there are red flags of suspected fraud.
- Coordinates ECU meetings and reports on active investigations and fraud referrals. Makes recommendations on the management of cases of suspected fraud.
- Coordinates communication and provides support to outside counsel managing suspected fraud cases.
- Prepares case summaries involving matters of suspected fraud.
- Conducts in-house background investigations using intranet social media and other sites and resources.
- Consults with outside counsel on matters and litigation pertaining to suspected fraud.
- Creates reports, presents regular updates to LifeCare management and to business partners, including reinsurers, regarding pending fraud investigations and fraud litigation.
- Assist client companies in the filing of, fraud reports as required by state Departments of Insurance.
- May assist in responding to Department of Insurance complaints.
- Testify in civil and criminal matters and, as required, coordinate communication with state and federal law enforcement and department of insurance fraud investigators. .
- Perform other duties consistent with the management of claims involving suspected fraud.
- Independently conducts company-wide fraud training as well as represents LifeCare in external training at LTCI and fraud conferences and stays abreast of legislative updates.
- Upholds performance standards and accepts new duties as necessary
- Performs all job duties in accordance with deadlines established by management
- Performs all job duties in accordance with departmental standards for accuracy, quality and productivity
- Performs other duties as required
Prerequisites for the Job:
- Demonstrates superior written and verbal communication skills
- Demonstrates superior organization skills
- Excellent attendance record
- Demonstrates high level of initiative
- Comfortable taking decisive and independent actions
- Five years or more previous long term care, disability, health and life, or workers’ compensation claims and/or SIU experience or equivalent. Deposition experience a plus.
- Bachelor’s Degree or equivalent; criminal justice degree preferred.
- Four years of investigative experience
- Must be computer literate; Working knowledge of AS400, Microsoft Office, ICD-9, CPT, PDR and Taber’s Reference Manuals
- Proficiency in oral and written English language communication
- Willingness to work cooperatively with others
- Detail-oriented and well organized
- Able to manage multiple tasks and projects under time constraints
- Previous experience using email, Internet, Windows and Microsoft Office and other applicable computer systems
- Ability to prioritize daily workflow of a moderate technical complexity.
- Demonstrate strong problem-solving and analytical ability.
- Physical and mental requirements for General / Professional personnel
All candidates must show proof of COVID-19 vaccination upon offer given, or become vaccinated after offer is given.
Please send resume to: firstname.lastname@example.org