Cleveland - BWC Fraud Analyst - PN: 20066666

About the role

Works under direction of Special Investigations Supervisors & primarily conducts internal & external record searches and/or review and cross reference of data to identify red flags for further investigation. Collaborates with the BWC Intelligence Unit to develop new data sets to analyze, collate, and mine for data anomalies and trends for further investigation. Generate allegations and investigative leads for the BWC special Investigation teams by utilizing the Fraud Management System (FMS), CORESuite, Internet, IBM Cognos, Tableau, Microsoft Excel as well as develop data from external sources, Criminal Justice data bases & other systems to effectively facilitate detection & investigation support. Acts as a lead worker establishing criteria to detect fraudulent activity & initiate investigations into allegations of fraud, abuse, & assist with development of detection ideas. Identifies behavioral trends &/or performs outlier analyses for stratified data populations; using computer technologies & advanced analysis techniques to design databases, compile & analyze large data sets in order to assist team in investigations of fraudulent schemes.

Requirements

• 54 months experience in private insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 months experience in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• OR completion of undergraduate core coursework in business, criminal justice, humanities, social & behavioral science, education or related field; 18 months experience in insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 months experience in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• OR 18 months experience as Workers' Compensation Claims Specialist, 16722, or managing caseload of workers' compensation lost-time disability claims which involved making decision to allow or deny claim, verifying appropriateness of medical treatment & charges, pre-authorized medical treatment, equipment, supplies & special travel arrangements, researching, negotiating, authorizing & issuing settlement of claims &/or conducting field inquiries to accurately assess claim information & resolving disputed condensability & benefit level for Ohio Bureau Of Workers' Compensation; 6 months experience in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• OR 18 months experience as BWC Fraud Investigator, 26261.

Pursuant to Ohio Administrative Code Chapter 4501 users of system shall adhere to policies & guidelines published in NCIC operating manual, CJIS security policy, LEADS operating manual, LEADS security policy, newsletters, & administrative messages from LEADS, all of which are either available on ODPS/LEADS intranet or disseminated to LEADS agencies; pursuant to LEADS security policy (revised 05/07/03) state & national fingerprint-based record checks must be conducted within 30 days of initial employment or assignment of all personnel, including appropriate IT personnel, having access to LEADS, or to records storage areas containing CCH/II data; minimum check must include submission of both a State of Ohio BCI& I card & an FBI applicant fingerprint card; both completed applicant fingerprint cards must be submitted by employing agency to State of Ohio Bureau of Criminal Identification & Investigation for processing & forwarding to Federal Bureau of Investigation; record of this check must be kept by employing agency & made available to LEADS upon request; fingerprint card returned by Ohio BCI&I is sufficient documentation. Pursuant to Ohio Administrative Code Chapter 4501 terminal agency shall conduct a complete background investigation of all terminal operators including, but not limited to: an applicant fingerprint card submission to BCI&I & FBI, an inquiry of state & national arrest & fugitive files; terminal agency is required to notify CTO of any applicant’s criminal record; existence of a criminal record may result in denial of access.

Skills

• Knowledge of Business, Criminal Justice, Humanities, Social & Behavioral Science Education or related field; BWC Policies & Procedures; Laws & Regulations related to Adjudication & Maintenance of Workers' Compensation Claims; Agency, State & Federal Statutes, rules, regulations & procedures applicable to investigation, evidence gathering & search & seizure; English; oral & written communication; public relations; interviewing techniques; principles of customer service; fundamental math operations; standard business practices. Requires some knowledge of disability insurance claims policies & procedures.
• Skill in use of personal computer; word processor; database & spreadsheet software; statistical analysis, data visualization & analytical software used in Fraud Detection.
• Ability to define problems, collect data, establish facts & draw valid conclusions; gather, collate & classify information about data, people or things; prepare meaningful, concise & accurate reports; communicate effectively & professionally with injured workers, employers, legislators, health care providers & public; make complex decisions regarding claims activity; read & understand medical reference manuals; write clear, concise & professional correspondence & reports; collate & classify information about data, people or things; assess immediate situation & make split-second decisions; respond to sensitive inquiries from & contacts with injured workers, employers, legislators, health care providers & members of general public.

Benefits

BWC offers flex-time work schedules that allow an employee to start the day as early as 7:00 am or as late as 8:30 am. Flex-time schedules are based on operational need and require supervisor approval.

Pay

$34.53 – $50.66 per hour

Schedule

Full-time, 40 hours per week. Core hours are Monday–Friday 8:00 am–5:00 pm, with daily start/end times varying by departmental need.