SIU Investigator

Allstate

2d•$60,000 - $104,100

About The Position

This job is responsible for investigating and analyzing complex and occasionally highly 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 complex losses and claims involving extra-contractual liability, medical losses in which suspicious activity has been identified. The individual performs a thorough investigation including; (1) conducting background searches; (2) taking recorded statements; (3) reviewing and analyzing medical notes & bills; and (3) conducting witness interviews and social media searches. The individual reviews whether fraud can be substantiated and supports a lawsuit. We are seeking a Special Investigation Unit (SIU) Investigator to conduct in‑depth investigations of accident and health insurance claims involving potential fraud. The ideal candidate brings a strong insurance claims background with experience reviewing medical claims to identify, analyze, and substantiate suspected fraudulent activity.

Requirements

strong insurance claims background
experience reviewing medical claims to identify, analyze, and substantiate suspected fraudulent activity
Analytical Thinking
Complex Claims
Data Analytics
Documentations
Health Insurance Claims
Insurance Claims
Medical Claims
Witness Interviewing

Responsibilities

Makes claim decisions regarding complex and occasionally highly complex investigations, and pursues restitution
Manages, researches, and resolves complex and occasionally highly complex customer communications, concerns, conflicts or issues
Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
Conducts thorough investigations of complex and occasionally highly complex multi-discipline claims and ECL claims that are potentially fraudulent to determine if payment is warranted
Utilizes analytic tools or SIU field intelligence to identify complex and occasionally highly complex claims for investigation and/or for support in the evidence of the fraud and damages
Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision making process
Enters SIU claim data information into multiple SIU systems
Updates files with investigation outcome, and when no fraud, or if insufficient evidence is found, returns file to MCO for further handling and settlement
Reviews investigations with fraud outcomes to validate whether denial is appropriate
Conducts complex and occasionally highly complex online data application searches, research, and evaluation