Job Summary

Under moderate direction, reviews analytic and technology tools to assess if additional investigation is necessary to identify and prevent fraud.  Utilizes a wide variety of investigative tools and techniques to complete investigative actions to aid in the investigation of suspect claims.  Works to continually assess and adapt our analytic tools and models to better identify suspect claims and potential fraud.  Works closely with the CNA SIU team to ensure timely assignment of investigations.

Essential Duties & Responsibilities

Performs a combination of duties in accordance with departmental guidelines:

1. Conducts detailed analysis of predictive analytic tools to determine if additional investigation is required.  Primarily triaging the models to the SIU investigative staff and on occasion completing thorough and timely investigations of suspected claim and/or provider fraud by following Best Practice Guidelines and collaborating with insureds, claimants, witnesses and experts.

    

2. Develops and executes investigation strategy in collaboration with claim professionals, counsel, experts, insureds, and other stakeholders.

    

3. Generally manages investigation activities independently, but requires guidance with unfamiliar or unusual issues; and coordinates/ oversees vendor service partner activities in the field.

    

4. Maintains detailed, accurate and timely case records by following established Best Practices for file documentation and by creating comprehensive reports of investigative findings, and conclusions.

    

5. Makes recommendations for claim and/or provider resolution by presenting findings and proposing solutions of moderate scope.

    

6. Participates in process and outcome improvements by analyzing, summarizing, and reporting on key metrics, identifying opportunities and participating in the design and implementation of process or procedural improvements.

    

7. Participates in building and enhancing organizational capabilities by developing and participating in the delivery of fraud awareness or regulatory compliance training and mentoring claim staff.

    

8. Contributes to knowledge sharing with outside agencies by presenting cases of suspected claim fraud and/or testifying on behalf of the company in civil or criminal matters.

    

9. Continuously develops knowledge and expertise related to insurance fraud by keeping current on related law, regulations, trends, and emerging issues and participating in insurance fraud or related professional associations.                                                                                                    

May perform additional duties as assigned.

Reporting Relationship

Typically Manager or Director

Skills Knowledge and Abilities

1. Solid knowledge of property and casualty claim handling practices. 2. Strong technical knowledge of practices techniques related to investigations and fact finding.  For roles focused in an area of specialty (medical provider investigations), strong technical knowledge of respective specialty practices is required. 3. Strong interpersonal oral and written communication skills; ability to clearly communicate complex issues. 4. Ability to interact and collaborate with internal and external business partners including outside agencies. 5. Ability to work independently exercise good judgment and make sound business decisions. 6. Detail oriented with strong organization and time management skills. 7. Strong ability to analyze complex, ambiguous matters and develop effective solutions. 8. Proficiency with Microsoft Office applications and similar business software and understanding of relational databases information querying techniques. 9. Ability to adapt to change and value diverse opinions and ideas. 10. Developing ability to implement change. 11. Ability to travel occasionally (less than 10%).

Education and Experience

1. Bachelor's degree or equivalent professional experience.2. Minimum of three to five years of claims handling or experience conducting investigations in the area of a) insurance fraud, b) law enforcement, c) civil or criminal litigation, or d) similar field. 3. Professional certification or designation related to fraud investigations strongly preferred (e.g., CFE, CIFA, FCLS, or similar).

*LI-KK1

Job

 Claim

Primary Location

United States-Illinois-Chicago

Organization

 Claims - Commercial