SIU - Senior Investigator (Southern CA)

PURPOSE OF THE JOB

The Senior Special Investigation Unit (SIU) Investigator works to detect, prevent, and investigate suspected fraudulent claims for all lines of insurance, with focus aligned to enterprise risk priorities. This position exists to protect company assets through examining potential fraudulent cases.

Essential Duties And Responsibilities

• Leads Complex and Major Case Investigations

• Counsels and interrogates claimants, witnesses, employers, medical providers, and legal representatives, utilizing advanced interviewing and interrogation techniques.

• Develops and secures recorded statements, affidavits, and evidence to support investigative findings.

• Performs on-site investigations, clinic inspections, and surveillance coordination as appropriate.

• Data Analysis & Intelligence Development

• Interprets and synthesizes large volumes of data from multiple sources, including claims systems, billing records, social media, and third-party databases.

• Identifies anomalies, trends, and networks/relationships indicative of fraud through link analysis and data correlation.

• Develops actionable intelligence packages to support internal stakeholders and external enforcement actions.

• Provider & Organized Fraud Focus

• Identifies and investigates fraud involving service providers, legal entities, and billing schemes, including upcoding, billing irregularities, and treatment patterns inconsistent with injuries.

• Coordinates with internal and external experts to evaluate medical necessity, treatment patterns, and provider networks.

• Fraud Detection & Case Development

• Evaluates referrals for fraud indicators and determines appropriate investigative strategies.

• Builds comprehensive case files supported by well-documented evidence, timelines, and investigative summaries.

• Ensures all findings meet standards required for regulatory reporting, civil litigation, and criminal prosecution.

• Collaborates with Legal & Regulatory Entities

• Presents investigative findings in a professional manner for case review, prosecution, or civil recovery actions.

• Maintains detailed knowledge of relevant laws, regulations, and evidentiary standards.

• Case Management & Reporting

• Produces clear, concise, and defensible investigative reports covering all aspects of the case lifecycle.

• Maintains accurate documentation in case management systems and ensures timely progression of cases.

Education And Experience

• Bachelor’s degree with a major in Criminal Justice, Business, Accounting, Information Systems, or closely related (or an equivalent combination of education/experience).
• Minimum of 5 years’ related work experience required.
• The Senior SIU Field Investigator requires experience specifically in investigations and/or law enforcement.

Certificates, Licenses, Registrations

• Private Investigator's License or fraud related certificates (CFE, CIFI) preferred.
• Requires valid Driver’s license.

Knowledge And Skills

• Good computer skills in Microsoft Office/Outlook and expertise using investigative case management software/tools (such as Polonious or similar).
• Experience with case management systems and investigative tools.
• Fundamental knowledge of claims management processes and claims handling.
• Knowledge of Unfair Claims Practices Act, Legislative, and Insurance Department regulatory requirements.
• Familiarity with civil/criminal investigation procedures and the legal system.
• Demonstrated experience with managing relationships to complete thorough investigations.
• High level of critical thinking, attention to detail, and independent judgment.
• Excellent written/verbal and presentation skills.
• Experience with advanced investigative and interviewing skills.
• Strong knowledge of fraud schemes, claims handling, legal procedures, and medical / services billing.
• Ability to analyze and interpret large, complex data sets.
• Ability to present information within a courtroom setting.

Physical Requirements

• Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear.

Work Environment

• This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.

Why Join ICW Group?

• Challenging work and the ability to make a difference
• You will have a voice and feel a sense of belonging
• We offer a competitive benefits package, with generous medical, dental, and vision plans as well as 401K retirement plans and company match
• Bonus potential for all positions
• Paid Time Off
• Paid holidays throughout the calendar year
• Want to continue learning? We’ll support you 100%
• ICW Group is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer.