This position is accountable for analytical and investigative activities (external and internal) related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud and to complete cases with all information and analysis for resolution, as the manager and prior approved guidelines may direct. This is a senior level investigator expected to conduct and resolve investigations and manage their caseload with limited management/supervisor oversight.
- Detects fraudulent activities by subscribers, providers, and other parties.
- Decides the most efficient and effective method of investigation appropriate for each individual case.
- Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.
- Provides evidence and/or testifies in cases where law enforcement agencies pursue prosecution.
- Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders.
- Represents the Company in conducting complex and potentially multi-million dollar settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
- Serves as Company’s representative in testifying in legal proceedings as required in fraud cases.
- Up to date and Knowledgeable about all applicable fraud statutes; Local, state and federal to ensure duties and assignments are carried out within the requirement of applicable law and local office expectations.
- Additional personal and professional attributes that are critical to successful performance:
- Building Partnerships
- Coaching
- Managing Conflict
- Negotiation
- Work Standards
- Tenacity
