SIU Field Investigator

Miami Neuroscience Institute Baptist Health South Florida; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare institution seeks a Fraud Investigator for its Special Investigations Unit in Northern New Jersey. The role involves complex investigations into potential fraud cases, requiring a strong background in investigations and multi-line insurance knowledge. Ideal candidates will have experience in the field and exemplary analytical skills.

Qualifications

• 5 or more years of experience preferred.
• Experience across multiple lines of insurance coverage.

Responsibilities

• Conduct thorough investigations including background searches and scene inspections.
• Perform surveillance and document findings in claim systems.
• Handle complex customer communications and issues.

Skills

Investigative skills

Analytical skills

Communication

Education

4 year Bachelor's Degree

Job description

This job is responsible for investigating and analyzing complex, multi-discipline coverage and claims that have been referred to the special investigation unit (SIU) for potential fraud. This role typically handles a combination of complex attorney represented and unrepresented claims and moderate to complex losses, in which suspicious activity has been identified. The individual performs a thorough investigation including; (1) conducting background searches, scene investigations, and clinic inspections; (2) taking recorded statements; (3) reviewing and analyzing medical notes, bills, and property damage; and (4) conducting witness interviews and social media searches. The individual conducts surveillance on property and/or creates scene reconstructions on some investigations and reviews whether fraud can be substantiated and supports a lawsuit. The individual provides work guidance and direction to less senior employees and provides mentoring and coaching to the team.

**This is a field-based position within our Special Investigations Unit (SIU) Fraud Investigation Department, responsible for conducting complex field fraud investigations. The ideal candidate must reside in or near Northern New Jersey, specifically in the Passaic, Bergen, or Hudson County areas. We are seeking candidates with a strong background in investigations, ideally with experience across multiple lines of insurance coverage, including homeowners insurance. A background in law enforcement or a similar investigative field is preferred. Prior SIU field experience highly preferred. **

Reviews investigations with fraud outcomes to validate whether denial is appropriate

Conducts complex site inspections, including body shops, medical clinics, loss locations etc.

Conducts complex online data application searches, research, and evaluation

Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads

Enters SIU claim data information into multiple SIU systems

Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement

Conducts thorough investigations of complex that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed

Utilizes analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages

Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process

Researches and responds to complex customer communications, concerns, conflicts or issues

Education
4 year Bachelors Degree (Preferred)

Experience
5 or more years of experience (Preferred)

Supervisory Responsibilities
This job does not have supervisory duties.