Description

Overview: (candidate can be located anywhere in the continental US) This can be a hybrid or fully work from home position.

Major Case Unit Investigator: Our operations team has an opening on our MCU Investigator team. 
This position is responsible for completing insurance fraud investigations and quality control of the final investigative product by providing a high level of technical expertise being delivered to our clients. The position requires the candidate to develop professional relationships with supported customers at the adjuster and management level. The perfect candidate for this role will have an in depth understanding of suspect and non-suspect claims investigations and will be able to communicate effectively to claims staff. 

Details:

JOB DESCRIPTION –

• 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.
• Prioritize assignments, conduct necessary field interviews, and exercise independent judgment, initiative and decision making when developing and following investigative leads.
• 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 contract.
• Assist clients as a subject matter expert/ expert witness, coordinate and attend Examinations Under Oath, and attend legal proceedings as required.
• Educate internal and external business partners (claims operations, internal adjusters, and underwriting staff) on ways to identify potentially fraudulent activity that may require further investigation.
• 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 creates 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.

QUALIFICATIONS –

• A four-year degree (Criminal Justice preferred) is desired – 4 years of sustained performance as an investigator, police officer, or military investigations may be substituted for 2 years of formal education.
• A minimum of five years of complex criminal investigative experience as a criminal investigator, detective and/or special agent in a full-time capacity, conducting fraud/economic related analysis.
• OR five (5) years of experience as a special investigator conducting insurance claim analysis and investigations with a carrier, third-party administrator and/or vendor contracted special investigations unit, plus one year conducting complex investigations.
• Detailed knowledge of field investigations, including preliminary research, set up, intelligence gathering, lead development, interviewing. And professional report writing. 
• Strong computer skills to include Word, Excel, PowerPoint, and Outlook
• Ability to learn new software operating systems and platforms. 

Requirements

Preferred professional designations from one of the following:

• Fraud Claim Law Specialist (FCLS)
• Fraud Claim Law Associate (FCLA)
• Certified Insurance Fraud Investigator (CIFI)
• Certified Fraud Examiner (CFE)
• Certified Financial Crime Investigator (CFCI)