Medical Fraud Investigator
Company Name: Travelers Import
Job Details
Duration:
Permanent
Min Education:
Not Specified
Salary:
Commensurate
Job Type:
Full Time
Min Experience:
Not Specified
Required Travel:
Location:
- USA - Naperville Illinois, 60540
Job Description
Solid reputation, passionate people and endless opportunities.
That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.
SUMMARY:
Position dedicated to investigation of national (country-wide) medical fraud cases to achieve results in fraudulent payout reduction. Provides and oversees investigative support and cooperation with prosecutors, law enforcement, the National Insurance Crime Bureau, insurance fraud bureaus, and counsel; through mutual exchange of intelligence in support of proactive investigations related to medical issues. This position provides leadership and strategic consulting to key business stakeholders within Travelers on the most complex of fraud schemes, trends and regulatory environment within significant first party medical and worker¿s compensation jurisdictions. Provides investigative expertise to limit exposure, protect the interest of our company and customers.
PRIMARY DUTIES:
Primarily responsible to conduct medical fraud investigations in complex, large, geographically dispersed cases with high exposure, etc.
Influence, guide and support proactive anti-fraud strategies aligned towards the pursuit of criminal or civil actions that are designed to detect and deter insurance fraud.
Strengthen organizational and team effectiveness through assessment and development of new anti-fraud capabilities within the Travelers.
Forecasts needs from emerging trends in the medical fraud arena (e.g., NICB and industry alerts, leads from lines of business, etc.)
Lead and contribute to the Travelers understanding of state specific 1st and 3rd party medical environments in auto, liability and worker¿s compensation. Partner with the insurance industry to design and champion positive legislation that will strengthen the regulatory environment.
Works closely with resources outside of SIU (e.g., business partners, NICB, other insurance carriers) to maximize efficiency and performance of the program
Responsible for building technical capabilities in Claim and Investigative Services staff to identify potential medical fraud in claim files. Provides advice and consultation, as subject matter expert, to SIU investigators and Claim staff.
May conduct missed opportunity reviews of claim files as needed (e.g., by LOB, by emerging trends, etc.). Researches/analyzes industry trends and best practices in the medical fraud investigation discipline to maximize results. Conducts risk analysis to determine/forecast and minimize potential exposures (e.g., use of chiropractors, durable medical equipment fraud, medical office procedures/protocol).
Manages expenses to stay within dedicated medical investigation budget (e.g., travel, equipment, supplies, etc.).
Builds relationship with Claim managers and other business partners (e.g., Legal, Medical Director, nurses, etc.) to assure that priorities are being identified and addressed.
May assist Claim to develop specific training programs/materials for the medical fraud program. Assists with marketing dedicated medical fraud unit services to business partners within and outside of Claim.
Establishes and maintains effective relationships with local/state/federal law enforcement personnel, national insurance crime bureau and local fraud agencies.
Stays knowledgeable on laws pertaining to fraud and insurance coverage.
Participates in the identification and selection of experts.
Works with attorneys to develop litigation strategies including development of affirmative litigation and to prepare experts to testify.
Conducts interviews, reviews documents and collects, identifies and safeguards evidence.
Assists in the identification and communicates of trends, makes recommendations to manager of the program. May draft medical position papers or best practices about claim handling procedures.
Testifies in court as appropriate.
Serves as the subject matter expert for regulatory and legislative issues relating to medical provider fraud.
Require some overnight travel.
EDUCATION/COURSE OF STUDY:
Minimum 4-year college degree or equivalent law enforcement or medical fraud claim experience. Additionally, the preferred candidates will posses medical, legal, or investigative credentials along with fluency in both English and Spanish.
Work Experience:
Minimum five years of Law Enforcement, Legal, Medical, or SIU experience. Significant specialized expertise in detecting and investigating medical fraud schemes in a multi-jurisdictional environment utilizing various investigative techniques and strategies. Litigation management experience related to affirmative prosecution preferred.
COMMUNICATION SKILLS:
Strategic communication.
Conflict management skills.
COMPUTER SKILLS:
Computer literate; database and Internet proficient
OTHER:
Knowledge of Claim, PL, CL and WC product lines.
Leadership, including delegation, organization and follow-up skills and ability to get work done through others.
Relationship management and Team Building.
Analytical Skills; problem solving and decision-making.
Presentation development and delivery skills.
Strong organizational skills and ability to set priorities to meet the needs of the business.
Strong interpersonal and customer service skills.
Strong verbal and written skills.
Strong analytical abilities to understand and resolve complex issues.
Computer skills: strong knowledge of Microsoft Office products.
Leadership: develops goals and drive
Travelers is an equal opportunity employer. We actively promote a drug-free workplace.
That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.
SUMMARY:
Position dedicated to investigation of national (country-wide) medical fraud cases to achieve results in fraudulent payout reduction. Provides and oversees investigative support and cooperation with prosecutors, law enforcement, the National Insurance Crime Bureau, insurance fraud bureaus, and counsel; through mutual exchange of intelligence in support of proactive investigations related to medical issues. This position provides leadership and strategic consulting to key business stakeholders within Travelers on the most complex of fraud schemes, trends and regulatory environment within significant first party medical and worker¿s compensation jurisdictions. Provides investigative expertise to limit exposure, protect the interest of our company and customers.
PRIMARY DUTIES:
Primarily responsible to conduct medical fraud investigations in complex, large, geographically dispersed cases with high exposure, etc.
Influence, guide and support proactive anti-fraud strategies aligned towards the pursuit of criminal or civil actions that are designed to detect and deter insurance fraud.
Strengthen organizational and team effectiveness through assessment and development of new anti-fraud capabilities within the Travelers.
Forecasts needs from emerging trends in the medical fraud arena (e.g., NICB and industry alerts, leads from lines of business, etc.)
Lead and contribute to the Travelers understanding of state specific 1st and 3rd party medical environments in auto, liability and worker¿s compensation. Partner with the insurance industry to design and champion positive legislation that will strengthen the regulatory environment.
Works closely with resources outside of SIU (e.g., business partners, NICB, other insurance carriers) to maximize efficiency and performance of the program
Responsible for building technical capabilities in Claim and Investigative Services staff to identify potential medical fraud in claim files. Provides advice and consultation, as subject matter expert, to SIU investigators and Claim staff.
May conduct missed opportunity reviews of claim files as needed (e.g., by LOB, by emerging trends, etc.). Researches/analyzes industry trends and best practices in the medical fraud investigation discipline to maximize results. Conducts risk analysis to determine/forecast and minimize potential exposures (e.g., use of chiropractors, durable medical equipment fraud, medical office procedures/protocol).
Manages expenses to stay within dedicated medical investigation budget (e.g., travel, equipment, supplies, etc.).
Builds relationship with Claim managers and other business partners (e.g., Legal, Medical Director, nurses, etc.) to assure that priorities are being identified and addressed.
May assist Claim to develop specific training programs/materials for the medical fraud program. Assists with marketing dedicated medical fraud unit services to business partners within and outside of Claim.
Establishes and maintains effective relationships with local/state/federal law enforcement personnel, national insurance crime bureau and local fraud agencies.
Stays knowledgeable on laws pertaining to fraud and insurance coverage.
Participates in the identification and selection of experts.
Works with attorneys to develop litigation strategies including development of affirmative litigation and to prepare experts to testify.
Conducts interviews, reviews documents and collects, identifies and safeguards evidence.
Assists in the identification and communicates of trends, makes recommendations to manager of the program. May draft medical position papers or best practices about claim handling procedures.
Testifies in court as appropriate.
Serves as the subject matter expert for regulatory and legislative issues relating to medical provider fraud.
Require some overnight travel.
EDUCATION/COURSE OF STUDY:
Minimum 4-year college degree or equivalent law enforcement or medical fraud claim experience. Additionally, the preferred candidates will posses medical, legal, or investigative credentials along with fluency in both English and Spanish.
Work Experience:
Minimum five years of Law Enforcement, Legal, Medical, or SIU experience. Significant specialized expertise in detecting and investigating medical fraud schemes in a multi-jurisdictional environment utilizing various investigative techniques and strategies. Litigation management experience related to affirmative prosecution preferred.
COMMUNICATION SKILLS:
Strategic communication.
Conflict management skills.
COMPUTER SKILLS:
Computer literate; database and Internet proficient
OTHER:
Knowledge of Claim, PL, CL and WC product lines.
Leadership, including delegation, organization and follow-up skills and ability to get work done through others.
Relationship management and Team Building.
Analytical Skills; problem solving and decision-making.
Presentation development and delivery skills.
Strong organizational skills and ability to set priorities to meet the needs of the business.
Strong interpersonal and customer service skills.
Strong verbal and written skills.
Strong analytical abilities to understand and resolve complex issues.
Computer skills: strong knowledge of Microsoft Office products.
Leadership: develops goals and drive
Travelers is an equal opportunity employer. We actively promote a drug-free workplace.