Claims Representative, SIU

Plymouth Rock Assurance • Woodbridge Township, NJ

9d • Onsite

About The Position

We are seeking a highly skilled and motivated candidate with specialized experience in NJ provider/PIP initiatives to join our team in order to assist with Major Case Investigation. The ideal candidate will have a strong background in identifying, investigating, and resolving complex cases of insurance fraud within the Personal Injury Protection (PIP) and healthcare provider space. Proficiency in investigative techniques, industry regulations, and PIP claim regulations is essential.

Requirements

• Minimum of 5 years of experience in insurance fraud investigation, with a focus on PIP claims and NJ provider networks.
• Proven expertise in the detection, investigation, and resolution of complex fraud cases in the insurance or healthcare industry.
• Strong understanding of New Jersey PIP laws, regulations, and claims processing.
• Proficiency in utilizing investigative tools, claims management software, and fraud detection systems.
• Excellent written and verbal communication skills, with the ability to present complex findings clearly and effectively.
• Ability to work independently, manage multiple investigations simultaneously, and meet deadlines.
• Strong analytical and problem-solving skills.
• Bachelor’s degree or equivalent experience in criminal justice, insurance, or a related field.

Responsibilities

• Lead and conduct comprehensive investigations into major fraud cases, including healthcare fraud, staged accidents, exaggerated injuries, and fraudulent billing practices related to PIP claims.
• Analyze and review claims data to identify red flags, trends, and patterns indicative of fraudulent activity, particularly focusing on NJ provider claims.
• Collaborate with internal teams, external stakeholders, and law enforcement agencies to gather evidence and build cases.
• Interview witnesses, claimants, and providers as part of the investigative process, documenting findings thoroughly.
• Provide detailed reports and recommendations on cases for potential legal action or denial of claims.
• Stay current with NJ PIP regulations, fraud detection techniques, and industry best practices.
• Work closely with legal, compliance, and claims teams to ensure that investigative findings align with company policies and regulatory requirements.
• Provide testimony and expert witness support in legal proceedings when necessary.

Benefits

• 4 weeks accrued paid time off, 8 paid national holidays per year, and 2 floating holidays
• Low cost and excellent coverage health insurance options that start on Day 1 (medical, dental, vision)
• Annual 401(k) Employer Contribution
• Free onsite gym and health center at our Woodbridge Location
• Resources to promote Professional Development (LinkedIn Learning and licensure assistance)
• Robust health and wellness program and fitness reimbursements
• Various Paid Family leave options including Paid Parental Leave
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level