Special Investigation Unit Investigator

We are seeking a detail-oriented and experienced SIU Investigator, specializing in medical provider fraud and premium fraud. The SIU Investigator will play a key role in protecting Pie and our customers by investigating suspicious claims, uncovering fraudulent activities, and ensuring the protection of the company’s financial interests. This role requires the SIU Investigator to identify, document, and resolve fraudulent claims, working in collaboration with law enforcement, legal departments, and other insurance professionals to ensure Pie's compliance with legal and regulatory standards for fraud detection, prevention and deterrence. 

How You’ll Do It

Investigations:

• Applies knowledge of state and federal laws, industry news, and trends as they relate to insurance fraud investigations.
• Responds to referrals from our internal team and will also independently and proactively analyze data to identify and investigate suspected instances of insurance fraud in both claims and underwriting.
• Conduct thorough investigations into suspected medical provider fraud, including billing discrepancies, overutilization of services, phantom billing, and kickback schemes.
• Investigate potential premium fraud involving misrepresentation of information related to policies, underwriting, and claims.
• Review medical records, claims data, financial statements, and other documents to identify fraudulent patterns or anomalies.
• Conduct interviews with claimants, insureds, medical providers, witnesses, and experts to gather evidence.
• Analyze claims, contracts, and healthcare service data to identify patterns indicative of fraudulent activity.
• Work with law enforcement and other state agencies in support of criminal investigations.
• Communicate with internal and external stakeholders while ensuring the confidentiality and security of sensitive information throughout the investigative process.

Reporting and Analytics:

• Prepare detailed investigative reports, documenting findings, evidence, and recommendations for further action.
• Prepares necessary reports for state fraud bureaus and cooperates with state agencies as required by law and management.
• Collect and analyze data from multiple sources to identify fraudulent activity, including claimant history, social media, and public databases.
• Use advanced data analytics tools to analyze large datasets for potential fraud indicators.
• Effectively communicates with the SIU team on general observations and provides ongoing feedback on trends and developments.

Vendor Management:

• Oversee all aspects of investigations assigned to investigative vendors.
• Make assignments to investigative panel members based on expertise, geographic coverage, and vendor’s performance metrics.
• Maintain oversight of assigned investigations to ensure that investigative efforts are in line with the established action plan, while making needed course corrections to ensure best possible outcomes.

Compliance:

• Completes assignments timely and accurately within company claim handling best practices and SIU investigation quality expectations.
• Ensures all investigations are conducted in accordance with Department of Insurance regulations, policies and/or procedures.
• Collaborate with internal teams, including claims adjusters, underwriters, and legal departments, to assess the validity of claims and investigate fraud risks.
• Stay updated on industry trends, emerging fraud schemes, and regulatory changes to improve investigative processes and strategies.
• Work with external partners, such as law enforcement, medical boards, and regulatory bodies, to support investigations and prosecutions.

The Right Stuff

• 5 years Performing SIU investigations for Workers Compensation and Commercial Auto Claims. 
• Bachelor's Degree in related field preferred. Insurance industry licenses, certifications or registrations such as; CIFI, CFE, SCLA, CAFP, AIS, FCLA, FCLS, CPCU, CIC.
• Demonstrated vendor oversight expertise.
• Demonstrated experience performing investigations to include developing evidentiary leads, interviewing investigative subjects and witnesses, and performing internet and informational databases research to include extraction and analysis.
• The candidate must be detail oriented, and have excellent written and verbal communication skills; must be customer service oriented and possess an understanding of Workers Compensation and Commercial Auto insurance contracts.
• Working knowledge of medical coding; CPT, HCPCS, Preferred.
• Proficient experience in insurance fraud investigations, especially medical provider fraud, waste and abuse investigations, premium fraud, payroll evasion, and misclassification investigations.
• Proficiency with Google Suite, Microsoft Outlook, Microsoft Word, and Microsoft Excel is needed.
• Demonstrated organizational skills to effectively manage assignments and workload.
• Must demonstrate a desire for continued professional development through continuing education and self-development opportunities.
• Up to 5% travel may be required for this position.