Early Fraud Warning Examiner (No Fault) (Hybrid)

NYCM Insurance•Edmeston, NY

3d•Hybrid

About The Position

EFW Examiners review claims for red flag indicators that will determine if further investigation and referral to special investigation unit (SIU) is needed. They also collaborate with examiners, supervisors and EFW examiners to reach mutual decisions on the disposition of claims that have been investigated. Duties & Responsibilities: Collaborate with the examiner teams to identify claims in need of further investigation. Work with examiners, customers, vendors, and other resources to gather information to establish facts of loss and if potential fraud indicators exist. Conduct objective, fair, thorough, and timely investigations, and reviews. Ensure processing of the claims are handled in accordance with regulation time frame. Submit claims to SIU through the database for assist or referral when fraud indicators are present. Return to examiner for normal claim processing when all red flag indicators have been ruled out. Generate detailed denials based on investigation findings when fraud is present. Submit provider bills on fraudulent claims to defense counsel for legal action. Review and sign legal documents for fraudulent claims submitted by defense counsel. Review and prepare files for hearings or settlement conferences as needed. Effectively communicate with all interested parties. Serve as a technical resource to examiners and others in the organization to increase awareness and identification of fraud indicators. Manage daily workload to stay current on new and existing claim files. Maintain reports of EFW related file activity. Maintain spreadsheets for quarterly tracking. Maintain current knowledge base of existing and emerging best practices, regulations, standards, guidance documents, and internal procedures. Participate in insurance related education to stay up to date on relevant fraud trends. Additional duties as assigned. Willingness to travel.

Requirements

High School Diploma
3 years claims or industry related experience
Full working knowledge and understanding of basic insurance principals and policies and claims procedures.
Basic working knowledge of court pleadings.
Strong interpersonal skills, with the ability to work within a team or independently without direct supervision.
Willingness and ability to engage in authentic conversations.
Good written and verbal communication skills.
Proficient with insurance policies, regulations, best practices.
Proficient personal computer skills including electronic mail, record keeping, Microsoft Word, Power Point and Excel.
Organized; ability to multi-task and prioritize.
Strong evaluation and decision-making abilities.
Ability to handle stress professionally, calmly, and effectively.
Critical thinking.
Positive and professional attitude.
Willingness to pursue professional development.

Responsibilities

Collaborate with the examiner teams to identify claims in need of further investigation.
Work with examiners, customers, vendors, and other resources to gather information to establish facts of loss and if potential fraud indicators exist.
Conduct objective, fair, thorough, and timely investigations, and reviews.
Ensure processing of the claims are handled in accordance with regulation time frame.
Submit claims to SIU through the database for assist or referral when fraud indicators are present.
Return to examiner for normal claim processing when all red flag indicators have been ruled out.
Generate detailed denials based on investigation findings when fraud is present.
Submit provider bills on fraudulent claims to defense counsel for legal action.
Review and sign legal documents for fraudulent claims submitted by defense counsel.
Review and prepare files for hearings or settlement conferences as needed.
Effectively communicate with all interested parties.
Serve as a technical resource to examiners and others in the organization to increase awareness and identification of fraud indicators.
Manage daily workload to stay current on new and existing claim files.
Maintain reports of EFW related file activity.
Maintain spreadsheets for quarterly tracking.
Maintain current knowledge base of existing and emerging best practices, regulations, standards, guidance documents, and internal procedures.
Participate in insurance related education to stay up to date on relevant fraud trends.
Additional duties as assigned.
Willingness to travel.