SIU Investigator - Major Investigations Team
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POST DATE 8/25/2016
END DATE 10/13/2016
JOB DESCRIPTIONSIU 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
* 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.
* Prepare detailed investigative reports.
* 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.
* Update claims and proprietary SIU data systems.
* Lead or assists in local branch training to enhance anti-fraud awareness.
* Keep current on state/territory issues, regulations, and trends.
* Participate in community-based anti-fraud associations.
SIU Manager or above
SKILLS, KNOWLEDGE & ABILITIES
* Ability to effectively investigate and contribute to positive impact.
* Solid interpersonal, verbal, and written communication skills, ability to effectively interact with internal/external team members, and business partners.
* Ability to work independently.
* Solid analytical skills with knowledge of link analysis and predictive modeling.
* Ability to exercise solid independent judgment and effectively make sound investigative case and business decisions.
* Solid comfort level and ability with technology tools, including Microsoft Office Suite (especially Excel), and other business related software tools/systems.
* Ability to travel, as required.
EDUCATION & EXPERIENCE
* Bachelor's degree or equivalent.
* Typically a minimum of 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.
Primary Location: United States-Pennsylvania-Wyomissing
Other Locations: United States-Pennsylvania-Wyomissing
Organization: CLAIM SS-WSL-Liab-SIU
Job Posting: Aug 24, 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.