Senior SIU Major Case (Medical Provider Investigations)

USAA•San Antonio, TX

1d•$93,770 - $179,240•Remote

About The Position

As a dedicated Senior SIU Major Case (Medical Provider Investigations), within defined guidelines and framework, protects USAA and our members from potential fraudulent claims by investigating complex fraud investigations with significant financial impact to USAA which may involve Legal Counsel, government agencies and outside consultants in compliance with state laws and regulations for an assigned operational specialty team. This role is remote eligible in the continental U.S. with occasional business travel.

Requirements

High School Diploma or General Equivalency Diploma
3 years of P&C SIU/Fraud Major Case investigation experience; or 4 years of medical provider claims experience (third-party BI experience does not qualify)
Expert knowledge and understanding of fraud investigations as well as application of case law and state laws and regulations.
Must be a results-oriented, skilled investigator with experience taking complex statements from multiple parties to an event.
Ability to gather broad range of evidence and draw conclusions based on objective details related to the applicability of fraud.
Demonstrated ability to organize and prioritize workload, performing multiple tasks and devising solutions to problems.
Experience using computers and various software packages to enter and extract data for analysis from relevant data sources and systems.
Knowledge of city, state and local regulations, legal concepts, understanding of contracts, case law, medical treatment, and medical terminology.
Experience in concurrent handling of specialty/complex/litigated claims/cases as well as mediation/arbitration/trial preparation and participation.

Nice To Haves

Experience developing cases for affirmative litigation
P&C Major Case Medical provider investigation experience
US military experience gained through military service or gained as a military spouse / domestic partner.

Responsibilities

Leads the execution of fraud prevention strategies and investigative operations.
Leads high exposure, high profile and sensitive work assignments, and special investigations involving complex specialized fraud referrals, (examples: organized provider rings, staged accidents, large losses of significant exposure and broad scale PIP/Casualty Schemes) across multiple entities or functions.
Applies advanced knowledge of P&C insurance industry products, services, and processes in investigating claims. This includes P&C insurance policy contracts and coverages and claims handling process and procedures.
Applies advanced knowledge of state laws and regulations pertaining to insurance fraud in investigating claims.
Processes large quantities of unstructured detailed information with high levels of accuracy by collecting evidence of potential fraud through field or remote interviews and thorough searches of investigative databases, internal resources, Internet resources, public records, and forensic tools.
Makes appropriate and prompt decisions to identify potential complex fraud within defined guidelines.
Prepares and presents detailed and comprehensive verbal and written investigative reports summarizing the results and outcome of the investigation.
Serves as subject matter expert for team members including providing expert guidance and training for fraud investigations.
Develops and maintains external relationships with industry, law enforcement and other contacts involved in fraud investigation, detection, and prevention.
Develops proactive actions and conveys compelling arguments to influence disposition of arbitrated and litigated cases effectively and efficiently.
Handles CAT duty responsibilities as business requires.
Ensure risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.