SIU Medical Provider Fraud Investigator
About The Position
This role is responsible for identifying suspicious medical provider businesses, attorneys, and law firms that may be connected for the purpose of generating fraudulent payments. The individual will conduct thorough investigations by identifying injured parties, billing trends, treatment sequences, attorney relationships, and claim reporting patterns. Responsibilities include conducting database searches, performing data mining, taking recorded statements, attending virtual depositions and mediations, and leading case investigation meetings. This role typically handles bodily injury claim files, including both non-litigation and litigation matters. We are seeking an experienced SIU Medical Provider Fraud Investigator, preferably located within the Central Time Zone, who holds an active Texas All-Lines Adjuster License or a reciprocal state license. The ideal candidate brings a strong investigative mindset with the ability to identify suspicious patterns, conduct complex medical provider fraud investigations, and thoroughly document findings. Success in this role requires exceptional organizational skills, attention to detail, analytical thinking, and the ability to manage multiple investigations effectively. Strong written and verbal communication skills are essential, along with the ability to collaborate with internal partners and present investigative findings in a clear, concise, and professional manner.
Requirements
- Holds an active Texas All-Lines Adjuster License or a reciprocal state license
- Strong investigative mindset
- Ability to identify suspicious patterns
- Ability to conduct complex medical provider fraud investigations
- Ability to thoroughly document findings
- Exceptional organizational skills
- Attention to detail
- Analytical thinking
- Ability to manage multiple investigations effectively
- Strong written and verbal communication skills
- Ability to collaborate with internal partners
- Ability to present investigative findings in a clear, concise, and professional manner
- Experience with SIU claim data entry
- Experience reviewing investigations with fraud outcomes
- Experience updating claim files with investigation outcomes
- Experience conducting complex online data application searches, research, and evaluation
- Experience conducting complex site inspections
- Experience conducting thorough investigations of potentially fraudulent claims
- Experience with scene investigations and surveillance
- Experience validating information and following up on leads
- Experience summarizing documents and entering into claim system notes
- Experience utilizing analytic tools or SIU field intelligence
- Experience researching and responding to customer communications
Nice To Haves
- Preferably located within the Central Time Zone
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
Benefits
- Comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse
- Monthly connectivity reimbursement for employees working from home
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
