Special Investigator/Provider/Workers Compensation – Mid or Senior Level

Salary Range: 102080 to 158409 (Currency: USD) (Pay period: per-year-salary)

PERFORMS INVESTIGATIONS OF SUSPECTED PROVIDER FRAUD

• Thoroughly reviews referrals from internal and external sources, investigating all indication of suspected fraud.
• Triages and logs referrals; prioritizes accordingly.
• Conducts review of publicly available and subscription-based databases and documentation to identify provider ownership, leadership, and operations.
• Recommends and executes courses of action to move investigations to resolution, including directing the work of outside investigators retained to provide investigative assistance to the Company.
• Documents all investigations thoroughly and in a manner compliant with various state Departments of Insurance and other law enforcement agencies.
• Prepares detailed reports and presentations regarding ongoing investigations, including findings and recommendations.
• Prepares and submits suspected and documented provider fraud referrals to law enforcement and prosecutorial agencies when appropriate. Responds to requests for information.
• Stays abreast of case progress and responds to any additional requests for information; If required, provides deposition and/or courtroom testimony.

ADDITIONAL RESPONSIBILITIES

• Collaborates effectively with Special Investigations Unit team members, senior management, and key internal partners (such as Medical Bill Review, Utilization Review, Claims Adjusting, and Legal) to share information and expertise, define investigative strategies and goals, and optimize the use of investigative outcomes to safeguard the company's interests.
• Maintains expertise in workers’ compensation provider fraud, investigative techniques, and legal requirements, staying informed about new developments and current trends in these areas.
• Keeps an active caseload list and diary of assigned investigations, managing workload to maximize efficiency.
• Conducts data analyses to identify potentially fraudulent policies and emerging schemes.
• Provides testimony related to provider investigations in various legal settings.
• Supports key anti-fraud personnel in identifying red flags.
• Assists in developing and presenting annual Special Investigations Unit training required by the Department of Insurance across multiple jurisdictions, and identifies opportunities for additional training to ensure timely and quality referrals by company staff. Provides courtesy training on provider fraud related topics to external parties (such as law enforcement, industry peers, etc.).
• Identifies, establishes, and cultivates external relationships with industry contacts and law enforcement involved in fraud investigation, detection, and prevention.
• Ensures strict confidentiality of all investigations.

REQUIRED QUALIFICATIONS

• EDUCATION: Minimum of high school diploma, or equivalent certificate, required. Bachelor's degree from an accredited four-year college or university preferred.
• DESIGNATIONS/CERTIFICATIONS: One or more preferred: Accredited Health Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Insurance Fraud Investigator (CIFI), Certified Insurance Fraud Analyst (CIFA), Certified Insurance Fraud Representative.
• EXPERIENCE: Minimum of 5 years of experience (10 years for Senior-level) in Special Investigations Unit specializing in provider or health care fraud involving workers compensation claims, or in law enforcement, or combination thereof, required.
• COMPUTER SKILLS: Must demonstrate strong technical competencies in the use of computers, standard business applications, Microsoft Office/365 applications, and Power BI and be able to master and become proficient in proprietary and vendor software programs.

LANGUAGE AND REASONING SKILLS

• Able to read and comprehend medical reports, medical billing, investigative reports, public records (e.g., licensing, ownership, etc.), claim file notes and attachments, legal documents, state-specific laws and regulations, moderately complex instructions, and business correspondence.
• Able to clearly and effectively draft detailed investigative reports, fraud referrals, and business correspondence.
• Able to effectively communicate with a wide range of internal and external parties.
• Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
• Able to solve practical problems involving several concrete variables in situations with limited standardization.

TRAVEL - Occasional travel one or more of the following required:

• Corporate Offices
• Offsite Meetings, Conferences and Industry Events
• Law Enforcement Agencies
• Provider Facilities
• Potential Witnesses (Field)
• Vendor Sites

WHAT WE OFFER

• Work Life Balance
• Work From Home Program (up to 2 days per week upon eligibility)
• Modern Office Setting
• Free On-Site Fitness Facility
• Two-minute walk from Walnut Creek BART Station
• Three-minute car ride from CA-24 and I-680
• Free On-Site Garage Parking
• Paid Time Off
• Paid Holidays
• Retirements Savings Match
• Group Health Insurance (Medical, Dental, and Vision)
• Life and AD&D Insurance
• Long Term Disability Insurance
• Accident and Critical Illness Insurance
• Flexible Savings Accounts
• Paid Community Volunteer Day
• Employee Assistance Program
• Tuition Reimbursement Program
• Employee Referral Program
• Diversity, Equity and Inclusion Program