Senior SIU Investigator

JOB OBJECTIVE:

The SIU investigator is responsible for the review, acceptance, action planning, investigation and documentation of suspect claims. The SIU investigator is the subject matter expert on insurance fraud and communicates directly with all levels of claims personnel with regard to investigative strategies and conclusions. The SIU investigator is responsible for fraud recognition training for claims personnel and agents and provides administrative record keeping on suspicious claim fraud for management, law enforcement, and resolution specialists.

ESSENTIAL FUNCTIONS:

• Review referred suspicious claims and identify the scope of investigation needed (full, limited or no investigation required) and provide feedback to the resolution specialist as needed on how to resolve the suspect issues in the claim.
• Investigate assigned suspicious claims.
• Determine and interview all parties who are material to the investigation.
• Independently perform investigative fieldwork to verify information and/or investigative leads.
• Utilize appropriate databases, informational resources and public records to verify information and/or investigative leads.
• Assign and oversee investigative vendors that are necessary for a thorough investigation including managing budgets and reports.
• Identify and communicate relevant coverage issues during the course of the investigation.
• Independently analyze data and facts to develop action plans and provide investigative conclusions.
• Perform other investigation and analysis as needed based on the requirements of the claim assignment.
• Prepare complete, detailed, and accurate narrative investigation reports, periodic status reports, and final opinions.
• Assist in the mentoring, development and providing of technical direction to other SIU investigators.
• Develop and mentor claims personnel regarding insurance fraud issues.
• Develop and coordinate training for SIU investigators in all phases of the investigation process.
• Work closely and communicate effectively with resolution specialists and claims leadership.
• Assist with fraud recognition training for resolution specialists and agents.
• Keep statistical data for transfer into SIU database and assist in developing data collection methods.
• Assist with and participate in examinations under oath.
• Review investigative results with resolution specialists and leadership before the claim is resolved.
• Appear in court as a company representative when needed.
• Represent SIU during claim reviews when needed.
• Assist in development of SIU field investigation standards and procedures.
• Generate and submit fraud reports to insurance departments.
• As directed by the SIU manager, may act as the department manager in the absence of the SIU manager.

Note: The SIU investigator is responsible for SIU investigations only. Resolution specialists are responsible for handling the claim including determining the amount of loss and negotiating settlements.

OTHER FUNCTIONS:

• Complete various special projects and investigations as assigned.
• Network with industry personnel, law enforcement, legal counsel and others to develop information for investigative analysis and leads.
• Act as a subject matter resource providing fraud awareness, investigative consultation and mentorship to resolution specialists.
• Prepare and maintain an accurate travel itinerary and expense reports.
• Perform other duties as assigned.

KNOWLEDGE. SKILLS AND EXPERIENCE:

• This position requires at least three years' experience in law enforcement, SIU investigation, or claims supervision; or at least four years as a resolution specialist.
• Multi-line insurance background is a plus.
• This position requires strong interviewing and investigative proficiency, strong interpersonal skills and organizational and analytical skills.
• Additionally, strong case management, communication and presentation skills and a thorough understanding of claims processes and procedures are necessary.
• This individual should have a college degree or equivalent experience in insurance.
• SIU Investigators shall possess the professional designation of CIFI (IASIU's Certified Insurance Fraud Investigator) or attain within 1 year of becoming and SIU Senior Investigator. Possess or attain the professional designation of FCLA (American Education Institute - Fraud Claims Law Associate) within 2 years of becoming an SIU Senior Investigator.