SIU Medical Provider Fraud Investigator

About the role

This role is responsible for identifying suspicious medical provider businesses, attorneys, and law firms that may be connected for the purpose of generating fraudulent payments. The individual will conduct thorough investigations by identifying injured parties, billing trends, treatment sequences, attorney relationships, and claim reporting patterns. Responsibilities include conducting database searches, performing data mining, taking recorded statements, attending virtual depositions and mediations, and leading case investigation meetings. This role typically handles bodily injury claim files, including both non-litigation and litigation matters.

Key Responsibilities

• Enters SIU claim data information into multiple SIU systems
• Reviews investigations with fraud outcomes to validate whether denial is appropriate
• Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement
• Conducts complex online data application searches, research, and evaluation
• Conducts complex site inspections, including body shops, medical clinics, loss locations etc.
• Conducts thorough investigations of complex claims that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed
• Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
• Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process
• 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
• Researches and responds to complex customer communications, concerns, conflicts or issues

Qualifications

• Active Texas All-Lines Adjuster License or a reciprocal state license
• Strong investigative mindset with the ability to identify suspicious patterns
• Ability to conduct complex medical provider fraud investigations and thoroughly document findings
• Exceptional organizational skills, attention to detail, analytical thinking, and the ability to manage multiple investigations effectively
• Strong written and verbal communication skills
• Ability to collaborate with internal partners and present investigative findings in a clear, concise, and professional manner
• Preferred location: Central Time Zone
• This job does not have supervisory duties

Skills

• Analytical Thinking
• Complex Claims
• Fraud Investigations
• Healthcare Fraud Prevention
• Insurance Claims Investigations
• Insurance Fraud
• Litigation
• Medical Codes
• Medical Malpractice
• Medical Record Auditing
• Witness Interviewing

Pay

SIU Cons I: $60,000.00 – $87,400.00/salary
SIU Cons II: $62,100.00 – $92,700.00/salary

Compensation is based on experience and qualifications. Total compensation for this role may include additional components, such as incentive pay (for example, commission or bonus), if applicable.

Schedule

This role is eligible to work from home. Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs. When working from home, you must have a dedicated, private workspace free from distractions, along with appropriate desk and seating. Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.