Work Comp Major Case Investigator

Location: Glendale, CA
Job_Code: 5784
# of Openings: 1

Job Brief
Remote Opportunity!

Work Comp Major Case Investigator | Remote Opportunity ( MUST have extensive CA Worker’s Compensation experience )

General Summary:

In support of the EMPLOYERS’ anti-fraud program goal to both protect EMPLOYERS against the adverse financial impact of workers’ compensation fraud and to ensure compliance with federal, state and local anti-fraud statutory/regulatory mandates, the Major Case Investigator provides knowledge and expertise in medical fraud, premium fraud, and knows how to develop complex cases as it relates to insurance fraud schemes. This investigator’s focus is directed towards multiple complex California case investigations with regional and nationwide implications. This investigator will have the skillset to pursue criminal prosecution of medical providers, claimants, policy holders, producers, attorneys, and other service providers that are suspected of having committed workers’ compensation fraud against EMPLOYERS, its member companies and its policyholders. This Investigator must have a strong insurance background, with a focus on investigations specific to Workers’ Compensation fraud schemes. #LI-Remote LP22

Essential Duties and Responsibilities:

• Worker’s compensation insurance experience
• Analyzes and summarizes highly technical information related to multiple complex case investigations with regional and national implications. Identifies irregularities, risks and next step actions through various means of pursuit. Has the ability to translate these findings to multiple internal and external customers and legal agencies.
• Makes key decisions regarding strategies for major case investigations involving multiple claims and/or organized fraud ring activity with regional and national impact.
• Proactively uses analytical skills and data analytics programs to identify potential areas of organized fraud activity or identify areas of vulnerability to fraud to develop investigative plans and/or solutions.
• Assists in forecasting needs from emerging trends in the major case and/or organized fraud arena in local area. (e.g., National Insurance Crime Bureau (NICB) and industry alerts, leads from all industry lines of business, etc.).
• Conducts technical training for investigative staff to build knowledge base in major case and/or fraud ring identification and investigative techniques.
• Applies critical thinking techniques to prioritize and develop investigations that have complex allegations and/or significantly financial impact to multiple claims and/or organized ring activity spanning state lines.
• Applies Local, State and Federal statutes to ensure investigations are carried out within the requirements of applicable law and local office expectations.
• Provides exceptional customer service by maintaining contact with internal business partners, customers and external resources throughout the life of each investigation.
• Acts as a liaison with local/state/federal law enforcement personnel, industry advocates and other companies.
• Serves as the subject matter expert (liaison) on fraud (medical and non-medical) to business and industry partners.
• Applies rules of evidence; recognizes evidence and determines its value to specific claim, evidence collection and interpretation.
• Assesses potential for lien consolidations, Qui Tams, bulk settlements, and is able to work with our panel attorneys to determine the best outcome to manage our risk.
• Establishes and maintains liaison network with public officials, law enforcement officers and others to obtain assistance in conducting investigations.
• Develops and maintains strong collaborative working relationships within EMPLOYERS, within the insurance industry and with law enforcement/prosecutorial agencies and organizations.
• Identifies cases of suspected fraud and prepares documented referrals for law enforcement.
• Testifies in court as required and prepares evidence as requested by the prosecution.
• May conduct claim file reviews for referral opportunities as needed (e.g., by line of business, by emerging trends, etc.).
• Ensures the timely and appropriate response to requests for information/assistance from law enforcement, prosecutorial and other authorized governmental agencies, pursuant to federal, state, and local statutes and regulations.
• Participates, as directed, in providing approved anti-fraud training to policyholders, producers, vendors, law enforcement and prosecutorial personnel.
• Travels on short notice by company vehicle or commercial carrier to various local or out of state destinations to perform investigative duties, appear in court, and meet with law enforcement/prosecutorial personnel or to provide or obtain training.
• Always exercises due diligence to protect EMPLOYERS against any unnecessary risks associated with the investigatory process.
• Other duties may be assigned.

Salary Range: $75,000 – $106,000 + comprehensive benefits package. Please follow the link to our benefits page for details! https://www.employers.com/careers/our-benefits-and-perks/

Job Requirements:

• Worker’s compensation insurance experience
• Knowledge of the civil remedies that can be pursued, including lien consolidations, Qui Tams, bulk settlements, etc.
• Detailed knowledge of medical fraud, American Medical Association CPT codes, CA Workers’ Compensation lien processes, premium fraud, claimant fraud, and be well-versed in emerging fraud trends.
• Bachelor’s degree in related field or equivalent experience.
• Attainment of an Advanced General/Specific Peace Officers Standards and Training certificate, or equivalent.
• Minimum of five (5) years of combined experience from any of the following areas:
• Insurance fraud investigations for a governmental agency (workers’ compensation experience preferred).
• Insurance fraud investigations for a private/public insurance carrier or private third-party administrator TPA (workers’ compensation experience preferred).
• Valid state drivers’ license and good driving record.
• Demonstrable working knowledge of federal, state, and local statutes, ordinances, regulations and case law pertaining to insurance fraud (preferably workers’ compensation insurance fraud) and of the criminal justice judicial system.
• Proven investigative skills.
• Superior oral and written communication, listening, interpersonal, customer service and telephone skills.
• Must be self-motivated with the ability to work independently with minimal direction and possess the abilities and skills to multi-task, to determine the relative importance of each task and issue, to adhere to deadlines, and to complete assignments accordingly.
• Excellent analytical, problem solving and decision-making skills and the ability to deal professionally with people in challenging situations.
• Ability to comply with Federal and State and local statutes, ordinances, and regulations regarding maintaining confidentiality.
• Possession of basic computer skills and understands relational database information querying techniques. (MS Office, Internet searches, Industry database familiarity, etc.)

Preferred But Not Required:

• Insurance claims examiner experience.
• Professional certification or designation related to fraud investigations preferred (CFE, FCLS, FCLA, or related).

Work Environment:

This role potentially and will routinely use office equipment such as computers, phones, printers, and web conferencing technology as examples.

• This is largely a sedentary role; however, some mobility is required
• May work early, late, or occasional weekend hours to accommodate business needs
• Occasional lifting of a maximum of 30lbs.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

Remote:

• This role is REMOTE friendly, but only open to candidates currently located in the United States .
• It requires a suitable space that provides a private and quiet workplace.

EXPECTED WORK HOURS: Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

TRAVEL: May be required to travel to off-site location(s) to attend meetings, as necessary

As a dynamic, fast-growing provider of workers’ compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work.

We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us profitably grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS.

Headquartered in Reno, Nevada, EMPLOYERS attributes its long-standing success to our most valuable resource, our employees. EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees.

We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. These are the pillars that support how we do business with our clients, and how we treat each other.

At EMPLOYERS, you’ll discover an energetic environment that inspires top achievement. As “America’s small business insurance specialist”, we have the resources, a solid reputation, and an expanding nationwide identity to enrich your work/life and enhance your career

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