The General is seeking a Special Investigator II to join our company. The Special Investigator II will organize, perform and track the investigation of claim activity that involves policy coverage issues and suspected fraud. Report status and results to adjusters and pertinent third parties on a regular basis according to established deadlines.
Essential Job Responsibilities
Investigates assigned claims suspected of insurance fraud and other irregularities; conducts timely, thorough, and accurate inquiries of the relevant facts necessary to support the Claim Adjuster’s decisions. Maintains assigned claim files in a confidential manner; documents all relevant facts pertaining to those files.
- Investigations include but not limited to taking detailed recorded statements from insured’s, claimants and witnesses, inspecting vehicles, proper collection of evidence and submission to forensic laboratories for analysis, conducts clinic inspections and creates reports on same, gather’s information about parties involved using databases, law enforcement agencies, public records and other available sources.
- Conducts investigations that have been identified as Major Cases. Investigations involve a high complexity, complex collusive activity, multiple parties, and multiple claims. Prepares, maintains, and presents a detailed and accurate investigative report to aid in the support of criminal/civil prosecutions.
- Perform critical in-depth research, analysis and review of medical procedures, records, and billings.
- Provide adjusters and claim supervisors with regular updates regarding status of investigations. When investigation is complete, submit an investigative report to the adjuster. Ensure that investigative vendors submit thorough final reports regarding their findings according to established deadlines.
- When suspected fraud is detected, submit thorough report regarding details of the incident and the investigation to appropriate law enforcement officials.
- Coordinate and consult with legal department on claim investigations and attend and/or conduct Examinations under Oath with Legal Counsel when appropriate.
- Prepare required notification to Department of Insurance regarding claims that are being investigated for possible fraud. Ensure that local Special Investigative Unit and Claims Department are complying with pertinent state regulations regarding the investigation of suspected fraud.
- Prepare status reports for management according to pre-determined deadlines.
- Create, organize, and instruct regular training programs for claims staff on subjects related to the detection of fraud.
- Evaluate the need for new investigative and database vendors. Notify SIU Management of potential new vendors for addition to vendor database.
- Maintain company issued equipment and vehicle. Prepare mileage reports for management according to pre-determined deadlines.
- Testifies in civil and criminal courts.
- Other duties as assigned.
- Three to five years of claims adjusting experience with a field investigative background required, or, three or more years experience in law enforcement with knowledge of effective investigative techniques.
- Bi Lingual abilities preferred.
- Must interact with and provide ongoing training to claims staff, and be able to develop contacts with local fraud bureaus, district attorney office’s, law enforcement agencies, insurance associations, etc.
- Must have an in-depth understanding of insurance coverages and develop investigative action plans in accordance with the coverage being investigated.
- Bachelor’s Degree in criminal justice or a related field or equivalent work experience required.
- Extensive law enforcement background a plus.
- Fraud Claims Law Specialist (FCLS) designation required.