SIU Investigation Adjuster Consultant II - Remote
About The Position
This job is responsible for investigating and analyzing complex, multi-discipline coverage and claims that have been referred to the special investigation unit (SIU) for potential fraud. This role typically handles a combination of complex attorney represented and unrepresented claims and moderate to complex losses, in which suspicious activity has been identified. The individual performs a thorough investigation including; (1) conducting background searches, scene investigations, and clinic inspections; (2) taking recorded statements; (3) reviewing and analyzing medical notes, bills, and property damage; and (4) conducting witness interviews and social media searches. The individual conducts surveillance on property and/or creates scene reconstructions on some investigations and reviews whether fraud can be substantiated and supports a lawsuit. The individual provides work guidance and direction to less senior employees and provides mentoring and coaching to the team.
Requirements
- 3+ years of previous SIU experience required
- Previous experience reviewing medical information and/or handling provider investigations
Nice To Haves
- Texas Adjuster License preferred
Responsibilities
- Enters SIU claim data information into multiple SIU systems
- Reviews investigations with fraud outcomes to validate whether denial is appropriate
- Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement
- Conducts complex online data application searches, research, and evaluation
- Conducts complex site inspections, including body shops, medical clinics, loss locations etc.
- Conducts thorough investigations of complex that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed
- Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
- Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process
- Utilizes analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages
- Researches and responds to complex customer communications, concerns, conflicts or issues
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
