Supervising Claims Fraud Investigator

About the role

Lead special investigations unit in the detection and investigation of Workers' Compensation fraud as well as other related employee availability related matters. Oversee investigations including the supervision and quality control of fieldwork, research, surveillance, interviews, social media, open-source methods, undercover methods and other means.

Responsibilities

• Manage and develop flow of referrals from internal, external and Third Party Administrator sources.
• Assist in the training of investigators, claim examiners and related staff in the recognition of suspicious claim activity.
• Assist counsel in the preparation of matters for hearings, trials and labor arbitrations.
• Form and lead joint investigations with law enforcement agencies and insurance carriers.
• Manage inventory through review of investigative work product of assigned staff.
• Guide and counsel investigators on their assignments.
• Assign matters and ensure the skillsets/resources necessary for success are available and utilized.
• Complete high level complex investigations.
• Performs other duties as assigned.
• Complies with all policies and standards.
• May be required to work hours outside regular work hours, as applicable.
• Observes the work performed by contractors, as applicable.
• Reviews invoices and approves them if the work has contractual standards, as applicable.
• Addresses performance issues with the contractor when possible, as applicable.
• Escalates issues to other parties when needed, as applicable.

Requirements

• Baccalaureate from an accredited college in Arts/Sciences (BA/BS) or an equivalent combination of education and experience.
• 7 years of insurance claim investigations or law enforcement detective work.
• 3 years of Insurance or Medical Fraud Investigation Experience.

Qualifications

• Knowledge of medical terminology, social media and occupational injury.
• Experience with surveillance and security camera systems.
• Experience testifying.