Cleveland - BWC Fraud Analyst - PN: 20066776

State of Ohio • Cleveland, OH

1d • Onsite

About The Position

The BWC Fraud Analyst applies claims knowledge to analyze fraud-detection outputs from crossmatches, data exchanges, and large-scale data sets, generating actionable investigative leads. This role collaborates with Research Analysts and the Intelligence Unit to interpret complex data trends, perform outlier analyses, and enhance fraud-detection methodologies and tools. The analyst serves as a liaison between the Intelligence Unit and fraud teams to assess investigative needs, refine detection criteria, and support the development of fraud-prevention strategies. Additionally, the analyst works closely with Intelligence Unit Fraud Data Specialists to develop tools, processes, and detection ideas, and assists in maintaining and supporting fraud-detection reports, visualizations, and detection programs (e.g., Cognos, Tableau).

Requirements

• 54 months of experience in a private insurance organization as a claims representative, criminal investigator, rehabilitation case manager, or equivalent position.
• 6 months of experience in the operation of a personal computer.
• Valid driver’s license.
• Completion of undergraduate core coursework in business, criminal justice, humanities, social & behavioral science, education, or related field.
• 18 months of experience in an insurance organization as a claims representative, criminal investigator, rehabilitation case manager, or equivalent position.
• 18 months of experience as a Workers' Compensation Claims Specialist, 16722, or managing caseload of workers' compensation lost-time disability claims which involved making decisions to allow or deny claims, verifying appropriateness of medical treatment & charges, pre-authorizing 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 compensability & benefit level for Ohio Bureau Of Workers' Compensation.
• 18 months of experience as a BWC Fraud Investigator, 26261.
• Knowledge of Business, Criminal Justice, Humanities, Social & Behavioral Science Education or related field.
• Knowledge of BWC Policies & Procedures, Laws & Regulations related to Adjudication & Maintenance of Workers’ Compensation Claims.
• Knowledge of Agency, State & Federal Statutes, rules, regulations & procedures applicable to investigation, evidence gathering & search & seizure.
• Knowledge of English.
• Knowledge of oral & written communication.
• Knowledge of public relations.
• Knowledge of interviewing techniques.
• Knowledge of principles of customer service.
• Knowledge of fundamental math operations.
• Knowledge of standard business practices.
• Skill in use of personal computer.
• Skill in use of word processor.
• Skill in use of database & spreadsheet software.
• Skill in use of statistical analysis, data visualization & analytical software used in Fraud Detection.
• Ability to communicate effectively & professionally with injured workers, employers, legislators, health care providers & public.
• Ability to make complex decisions regarding claims activity.
• Ability to read & understand medical reference manuals.
• Ability to write clear, concise & professional correspondence & reports.
• Ability to collate & classify information about data, people or things.
• Ability to assess immediate situation & make split-second decisions.
• Ability to respond to sensitive inquiries from & contacts with injured workers, employers, legislators, health care providers & members of general public.
• Must successfully pass state highway patrol personal background check prior to employment.
• 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.
• 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.
• The existence of a criminal record may result in denial of access.

Nice To Haves

• 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.

Responsibilities

• Applies claims knowledge to analyze fraud‑detection outputs from crossmatches, data exchanges, and large‑scale data sets, generating actionable investigative leads.
• Collaborates with Research Analysts and Intelligence Unit to interpret complex data trends, perform outlier analyses, and enhance fraud‑detection methodologies and tools.
• Serves as a liaison between Intelligence Unit and fraud teams to assess investigative needs, refine detection criteria, and support the development of fraud‑prevention strategies.
• Works closely with Intelligence Unit Fraud Data Specialists to develop tools, processes, and detection ideas.
• Assists in maintaining and supporting fraud‑detection reports, visualizations, and detection programs (e.g., Cognos, Tableau).

Benefits

• Medical Coverage
• Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
• Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
• Childbirth, Adoption, and Foster Care leave
• Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
• Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree