Investigative Services Unit Specialist

SUMMARY: 

The Investigative Services Unit Specialist is a Subject Matter Expert (SME) on potential fraud cases and related investigative activities affecting AF Group. The primary function of the ISU Specialist is to detect and deter insurance fraud and to use developed knowledge, skills, and abilities to support the mission of AF Group and comply with state regulatory requirements. The Specialist will effectively manage day-to-day investigative assignments by providing timely, quality, and cost-effective investigative results to field staff. When potential fraud cases are identified, the Specialist will conduct thorough investigations, document results, coordinate mitigation strategies, make appropriate recommendations, and required notifications. 

 Under the direction of the ISU Director, this position is responsible for fraud investigations, compliance with state regulatory requirements, liaison with law enforcement, anti-fraud training, and ISU quality assurance. Investigations could include complex financial fraud and organized fraud-ring schemes. The ISU Specialist directs vendor investigations, examines investigative reports, reviews surveillance video, and determines if further investigation is warranted. The Investigative Specialist will review vendor invoices for accuracy and contract compliance. The Specialist collaborates with stakeholders to coordinate mitigation strategies and risk management. The ISU Specialist is responsible for educating internal and external customers on the department’s capabilities and effectiveness and provides training on reporting potential fraud. 

RESPONSIBILITIES/TASKS:  

• Communicates and collaborates with departmental stakeholders to promote open lines of communication and appropriate referrals for investigation.
• Assess, triage, and prioritize referrals received to develop investigative plan.
• Direct, communicate, and manage work assigned to investigative vendors. 
• Analyze intelligence information and make determination for further investigation utilizing available resources, knowledge of fraud schemes and investigation strategies.
• Conduct investigations to include desk and field investigations, and interviews of involved parties. Obtain, review, and analyze relevant documents and records.
• Fraud investigations conducted to include claimants, medical and ancillary providers, premium avoidance, and other schemes related to workers compensation, property, casualty, commercial auto, trucking, and surplus coverage.
• Coordinate and direct onsite investigation of catastrophic claim incidents as requested by claim adjustors.
• Prepares comprehensive investigation reports and documents all findings and developments in the case management system. 
• Comply with all state regulations related to reporting potential fraud. 
• Conducts follow-up on fraud referrals and monitors the status of a case through prosecution. Testifies in court proceedings when required. 
• Responds to subpoena and other external record requests in accordance with AF Group procedures. 
• Determines loss incurred and seek restitution or civil recovery.
• Assesses investigative results to determine savings achieved.
• Establishes and maintains external relationships with law enforcement, trade organizations and others involved in the investigation of insurance fraud.  
• Consistently monitors workflows to maximize efficiency.
• Monitor vendor performance standards and service levels. May make recommendations for metrics used to measure vendor performance.
• Analyzes trends and completes comprehensive and detailed reports.
• Reconcile vendor billing and follow up with accounts payable/vendors regarding vendor accounting issues.
• Evaluates training needs and designs and develops training modules, materials and evaluations related to fraud for internal and external customers as needed.
• Maintains up-to-date technical knowledge of investigative core functions. 
• Deliver presentations as needed.
• Use independent judgment in all areas of responsibility, while considering department and division priorities.
• Coordinates with enterprise companies in the development and management of ISU.
• Additional duties and projects assigned.

This position description identifies the responsibilities and tasks typically associated with the performance of the job. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION OR EQUIVALENT EXPERIENCE:  

Bachelor’s degree in business, criminal justice, law enforcement, insurance, or related field of education required. Knowledge of insurance fraud and other relevant civil and criminal laws is preferred. An equivalent combination of education and experience may be considered in lieu of degree, preference given to degree. Continuous learning required, as defined by the Company’s learning philosophy. Certification, or progress toward, highly preferred and encouraged.

EXPERIENCE:

With proper education credentials, minimum of seven years of law enforcement and/or insurance claims investigations required. Workers’ compensation experience and/or experience in a property/casualty insurance organization preferred. 

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: 

1. Strong interpersonal and superior communication skills Must be customer oriented and able to represent the department in meetings with internal and external stakeholders.
2. Strong writing skills with proven ability to synthesize and document complex case investigation results and prepare presentations. 
3. Demonstrated leadership abilities.
4. Ability to work independently and collaborate on group projects.
5. Strong knowledge of laws, regulations, and compliance requirements related to insurance.
6. Demonstrated technical knowledge of insurance administration, claims management, or relevant insurance expertise.
7. Strong background in word processing, spreadsheets, and graphics programs required with knowledge of Microsoft applications preferred.
8. Ability to analyze and synthesize large data sets and complex policy, financial and medical records.
9. Ability to analyze and interpret documents for accuracy in reference to technical, legal, and financial information.
10. Ability to effectively exchange information clearly and concisely, present ideas, report facts, and other information, and respond to questions as appropriate, both in oral and written communications.
11. Ability to quickly make decisions and comprehend the consequences of various problem situations and take appropriate actions and/or refer problems for necessary decision making.
12. Ability to organize and prioritize multiple assignments.
13. Ability to maintain confidentiality,
14. Ability to perform other assignments at locations outside the office.
15. Ability to work with minimal supervision.

WORKING CONDITIONS:

Work is performed in a home setting with no unusual hazards. Occasional travel required. Must possess a valid driver’s license with a record that meets corporate standards. Work is required at various times of the day and sometimes weekend work may be required. 

PAY RANGE:
Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $73,600 - $123,200.

We are an Equal Opportunity Employer. We will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.

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The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge, and ability levels associated with performing the duties and responsibilities contained in this job description.