SIU Investigator - Major Investigations Team 9/10/2016

CNA Brea, CA

Company
CNA
Job Classification
Full Time
Company Ref #
8f697bffdd2f09cfdc84787fbcb9ded9
AJE Ref #
576134221
Location
Brea, CA
Experience
Mid-Career (2 - 15 years)
Job Type
Regular
Education
Bachelors Degree

JOB DESCRIPTION

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SIU CONSULTANT: HEALTHCARE FRAUDS & ORGANIZED CRIMES

CNA Insurance is currently recruiting for a highly-specialized position in the Major Investigations Team of our Special Investigations Unit. The candidate chosen for this position will work as an investigator on a nationwide team of investigators, medical consultants, and intelligence analysts specifically dedicated to uncovering healthcare/provider frauds and associated organized crimes.



Qualified candidates for this position should have considerable investigative

experience in private insurance workers compensation and commercial bodily

injury claims including specific knowledge of, and direct experience with:

Medical bill coding,

Medical treatment guidelines,

Medical professional scopes of practice,

Criminal investigative methods to uncover healthcare/provider related fraud, waste, and abuse,

Evidentiary procedures, including tying relevant evidence to elements of a

crime or regulatory violation,

Anti-fraud abatement and mitigation strategies.

Essential Duties & Responsibilities



1. Investigate, analyze, and evaluate suspected patterns-of-practice of fraud

across a multitude of claims through the performance of unbiased,

detailed, fact-based investigations, extensive document examination,

evidence procurement, and contact with insureds, patients, witnesses,

healthcare professionals, and other experts.

2. Prepare detailed investigative reports.

3. May prepare cases for presentation to local, state, or federal prosecutors

in pursuit of criminal actions, to state regulatory boards in pursuit of

actions against professional licensing, and may be required to testify on

behalf of CNA in administrative, regulatory, civil, or criminal cases.

4. Update claims and proprietary SIU data systems.

5. Lead or assists in local branch training to enhance anti-fraud awareness.

6. Keep current on state/territory issues, regulations, and trends.

7. Participate in community-based anti-fraud associations.

Skills, Knowledge & Abilities



1. Ability to effectively investigate and contribute to positive impact.

2. Solid interpersonal, verbal, and written communication skills, ability to

effectively interact with internal/external team members, and business

partners.

3. Ability to work independently.

4. Solid analytical skills with knowledge of link analysis and predictive

modeling.

5. Ability to exercise solid independent judgment and effectively make sound

investigative case and business decisions.

6. Solid comfort level and ability with technology tools, including Microsoft

Office Suite (especially Excel), and other business related software

tools/systems.

7. Ability to travel, as required.

Reporting Relationship

SIU Manager or above

Education & Experience



1. Bachelor's degree or equivalent.

2. Minimum five to seven years of specific healthcare/provider fraud and

organized crime investigative experience in private insurance workers

compensation as an SIU-Oriented Claim Adjuster, Major Case SIU

Investigator, and/or SIU-Oriented Medical Case Management Nurse.



*LI-AM1

Job: Claim
Primary Location: United States-California-Brea
Other Locations: United States-California-Brea
Organization: CLAIM SS-WSL-Liab-SIU
Job Posting: Sep 9, 2016
Unposting Date: Ongoing.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.