SIU - Senior Investigator

ICW Group•CA - Remote, CA

1d•$78,679 - $132,686•Remote

About The Position

The Senior Special Investigation Unit (SIU) Investigator works to detect, prevent, and investigate suspected fraudulent claims for all lines of insurance, with focus aligned to enterprise risk priorities. This position exists to protect company assets through examining potential fraudulent cases. The work is aligned to either Desk or Field investigative assignments.

Requirements

Bachelor’s degree with a major in Criminal Justice, Business, Accounting, Information Systems, or closely related (or an equivalent combination of education/experience).
Minimum of 5 years’ related work experience required.
The Senior SIU Field Investigator requires experience specifically in investigations and/or law enforcement.
Good computer skills in Microsoft Office/Outlook and expertise using investigative case management software/tools (such as Polonious or similar)
Experience with case management systems and investigative tools
Fundamental knowledge of claims management processes and claims handling
Knowledge of Unfair Claims Practices Act, Legislative, and Insurance Department regulatory requirements
Familiarity with civil/criminal investigation procedures and the legal system
Demonstrated experience with managing relationships to complete thorough investigations
High level of critical thinking, attention to detail, and independent judgment
Excellent written/verbal and presentation skills
Experience with advanced investigative and interviewing skills
Ability to analyze and interpret large, complex data sets
Strong knowledge of fraud schemes, claims handling, legal procedures, and medical / services billing
Ability to present information within a courtroom setting
Requires valid Driver’s license.

Nice To Haves

Private Investigator's License or fraud related certificates (CFE, CIFI) preferred.

Responsibilities

Leads Complex and Major Case Investigations: Conducts advanced, large-scale investigations involving organized fraud rings, provider fraud schemes, (medical, legal, and ancillary services), referral/kickback schemes. Identifies patterns of coordinated activity across multiple claims to detect systemic and enterprise-level fraud risks. Independently manages complex, multi-jurisdictional cases from inception to resolution. Interviews claimants, witnesses, employers, medical providers, and legal representatives, utilizing advanced interviewing and interrogation techniques. Develops and secures recorded statements, affidavits, and evidence to support investigative findings. Performs on-site investigations, clinic inspections, and surveillance coordination as appropriate.
Data Analysis & Intelligence Development: Interprets and synthesizes large volumes of data from multiple sources, including claims systems, billing records, social media, and third-party databases. Identifies anomalies, trends, and networks/relationships indicative of fraud through link analysis and data correlation. Develops actionable intelligence packages to support internal stakeholders and external enforcement actions.
Provider & Organized Fraud Focus: Identifies and investigates fraud involving service providers, legal entities, and billing schemes, including upcoding, billing irregularities, and treatment patterns inconsistent with injuries. Coordinates with internal and external experts to evaluate medical necessity, treatment patterns, and provider networks.
Fraud Detection & Case Development: Evaluates referrals for fraud indicators and determines appropriate investigative strategies. Builds comprehensive case files supported by well-documented evidence, timelines, and investigative summaries. Ensures all findings meet standards required for regulatory reporting, civil litigation, and criminal prosecution.
Collaborates with Legal & Regulatory Entities: Partners closely with law enforcement, district attorneys, regulatory agencies, and legal counsel to advance cases. Presents investigative findings in a professional manner for case review, prosecution, or civil recovery actions. Maintains detailed knowledge of relevant laws, regulations, and evidentiary standards.
Case Management & Reporting: Produces clear, concise, and defensible investigative reports covering all aspects of the case lifecycle. Maintains accurate documentation in case management systems and ensures timely progression of cases.