SIU Senior Consultant

CNA • Walnut Creek, CA

4d • Hybrid

About The Position

Under minimal direction, the SIU Senior Consultant initiates and manages suspected provider fraud investigations involving the most complex matters, specifically within California. The role requires knowledge of complex fraud schemes and emerging trends, familiarity with law enforcement processes and reporting requirements, strong analytical skills, and the ability to testify credibly when called upon. The investigator should have in-depth knowledge of fraud schemes prevalent in California and working knowledge of state regulations, B&P Codes, CPT Codes, and other applicable investigative tools. Knowledge of Qui Tam litigation, lien consolidations, and other civil remedies is preferred. The position advises, directs, and supports technical claim teams and counsel in detecting, investigating, and litigating suspected claims. It is hybrid and based at one of CNA’s California offices in Walnut Creek, Los Angeles, Brea, Irvine, or San Diego.

Requirements

• Bachelor’s degree or equivalent professional experience.
• At least eight years of experience conducting or directing investigations in insurance fraud, law enforcement, civil or criminal litigation, or a similar field.
• Advanced knowledge of property and casualty claim-handling practices.
• Superior or expert technical knowledge of investigative and fact-finding practices and techniques.
• Excellent interpersonal, oral, and written communication skills, including the ability to synthesize and communicate complex issues to all levels of the organization.
• Ability to interact and collaborate with internal and external business partners, including outside agencies.
• Ability to work independently, exercise good judgment, make sound business decisions, and develop others.
• Strong organization, attention to detail, and time-management skills.
• Ability to analyze highly complex, ambiguous problems and develop and implement effective solutions.
• Proficiency with Microsoft Office applications and similar business software, and understanding of relational databases and information-querying techniques.
• Ability to lead change while valuing diverse opinions and ideas.
• Ability to implement proactive, long-term strategies in support of business objectives.
• Knowledge of California fraud schemes, state regulations, B&P Codes, CPT Codes, law-enforcement processes, and reporting requirements.
• Ability to testify credibly when called upon.

Nice To Haves

• Advanced degree highly desired.
• Professional certification or designation related to fraud investigations strongly preferred, such as CFE, CIFI, FCLS, FCLA, or similar.
• Strong knowledge of Qui Tam litigation, lien consolidations, and other civil remedies.

Responsibilities

• Lead detailed analysis and complete thorough, timely investigations of suspected claim fraud using Best Practice Guidelines and collaborating with insureds, claimants, witnesses, and experts.
• Develop and execute investigation strategies independently or in collaboration with claim professionals, counsel, experts, insureds, and other stakeholders.
• Manage investigation activities independently and/or coordinate and oversee vendor service partner activities in the field.
• Maintain detailed, accurate, and timely case records and prepare comprehensive reports of investigative findings and conclusions.
• Recommend claim resolutions by presenting findings and proposing solutions of moderate to complex scope.
• Identify opportunities and participate in designing and implementing process or procedural improvements.
• Lead or direct efforts to build and enhance organizational capabilities by developing and delivering fraud-awareness or regulatory-compliance training and mentoring lower-level SIU staff.
• Lead or direct case preparation for presentation to outside agencies and the pursuit of criminal or civil actions by gathering and documenting relevant data, organizing and summarizing facts, and testifying for the company in civil or criminal matters.
• Maintain and develop insurance-fraud expertise by keeping current on related laws, regulations, trends, and emerging issues and participating in insurance-fraud or related professional associations.
• Provide advice, direction, and support to technical claim teams and counsel on detecting, investigating, and litigating suspected claims.

Benefits

• Comprehensive and competitive benefits package intended to support employees’ and family members’ physical, financial, emotional, and social wellbeing.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior