Cambridge - BWC Fraud Analyst -PN: 20066658

State of Ohio • Cambridge, OH

1d • Hybrid

About The Position

This position involves investigating and adjudicating fraudulent activity within the Ohio Bureau of Workers' Compensation (BWC). The role may include acting as a lead worker, providing work direction and training to lower-level fraud investigators. Responsibilities include monitoring cases, conducting case reviews, critiquing reports of investigation, preparing reports for Industrial Commission hearings, and managing claims activities such as benefit adjustments, overpayment declarations, and medical payment stoppages. The position requires adherence to various state and federal policies and guidelines related to data security and investigations.

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 decision to allow or deny claim, verifying appropriateness of medical treatment & charges, pre-authorized 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 condensability & 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 &/or 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 data base & spreadsheet software
• Skill in use of analytical software used in Fraud Detection
• Skill in use of surveillance equipment (e.g., 35 mm camera; camcorder; mini camera; undercover audio recording devices)
• 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 & 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
• Both completed applicant fingerprint cards must be submitted by employing agency to State of Ohio Bureau of Criminal Identification & Investigation for processing & forwarding to Federal Bureau of Investigation
• Record of this check must be kept by employing agency & made available to LEADS upon request
• Fingerprint card returned by Ohio BCI&I is sufficient documentation
• 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
• Terminal agency is required to notify CTO of any applicant’s criminal record
• Existence of a criminal record may result in denial of access

Nice To Haves

• Completion of undergraduate core coursework in business, criminal justice, humanities, social & behavioral science, education or related field
• 18 mos. exp. as Workers' Compensation Claims Specialist, 16722, or managing caseload of workers' compensation lost-time disability claims which involved making decision to allow or deny claim, verifying appropriateness of medical treatment & charges, pre-authorized 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 condensability & benefit level for Ohio Bureau Of Workers' Compensation
• 18 mos. exp. as BWC Fraud Investigator, 26261

Responsibilities

• Acting as a lead worker (i.e. providing work direction & training) over lower-level BWC fraud investigators in investigation and adjudication of fraudulent activity
• Monitoring cases and conducting case reviews with assigned BWC fraud investigator(s) to determine progress and to ensure proper steps are taken
• Reviewing/critiquing report of investigation completed by investigative staff and ensuring accuracy, completeness and thoroughness of report of investigation and determining if fraud has been established and when applicable, writing claim summary, six elements of fraud and action requested
• Preparing report of investigation for Industrial Commission (i.e. IC) hearings
• Preparing BWC orders or motions for IC requesting specific actions based on investigation results
• Monitoring & documenting claims activities (e.g. adjusts benefit plans; declares overpayment allocations; stops improper medical payments; issues recoupment correspondence; prepares recovery packets; calculates, inputs, adjusts overpayment and actuarial savings totals; prepares actuarial spreadsheet in conjunction with managed care organization)

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