SIU Major Case Manager (Medical Provider)

USAA•San Antonio, TX

1d•$119,310 - $228,040•Remote

About The Position

As a dedicated SIU Major Case Manager (Medical Provider), you will be responsible for operational management of Claims fraud investigative teams. Directs staff in the investigation of cases involving questionable, suspect, or fraudulent activity. Ensures compliance with policies and procedures contributing to fraud control objectives, as well as compliance with state insurance fraud-related laws and regulations. This role is remote eligible in the continental U.S. with occasional business travel.

Requirements

Bachelor's degree; OR 4 years of relevant education and/or experience.
2 years of demonstrated leadership experience, supervisory or management experience in major case medical provider.
6 years’ experience in medical provider fraud and P&C industry functional work OR 4 years of medical provider P&C experience plus military service experience.
Experience supporting and developing affirmative litigation referrals and collaborating with counsel on fraud-related legal actions.
Demonstrated ability to manage multiple high-priority investigations and case assignments simultaneously while meeting critical deadlines.
Experience handling large-scale, complex, and high-exposure fraud investigations from initial referral through resolution.
Extensive knowledge and experience in all levels of claims investigation or fraud investigation and regulatory reporting requirements.
Knowledge of anti-fraud analytics programs relates to fraud prevention and identification.
Thorough understanding investigative tools and techniques to guide and coach special investigators.
Demonstrated ability to build and maintain collaborative relationships with internal and external partners and business areas.

Nice To Haves

US military experience gained through military service or gained as a military spouse / domestic partner.

Responsibilities

Responsible for insurance fraud detection and investigation services to reduce fraud-related claim payments and costs, while avoiding unwarranted risk.
Ensure compliance with laws and regulations relating to claims handling and unfair claims practices and reporting statutes.
Participates in the establishment and implementation of policies and procedures for fraud control and investigative practices.
Performs leadership and management tasks, i.e., providing coaching, evaluating performance, review of time sheets, managing time off, conducting quarterly check-ins/ride-alongs, etc.
Evaluates, authorizes, and implements actions and decisions to carry out proactive claim's projects and investigations.
Review and evaluate investigation recommendations from investigators to ensure results and case documentation support conclusions.
Ensure risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.
Demonstrated management skills and the ability to demonstrate monthly productivity and cycle time outcomes from investigations assigned to the SIU team.
Ability to prepare and present training sessions and case outcomes.
Demonstrated experience facilitating and managing projects and teams