Associate Fraud Specialist - Woodland Hills

Position Summary


 


Under close supervision, responsible for the oversight and investigation of  workers? compensation fraud, medical provider fraud, premium fraud and other complex or sensitive investigations.  Assists the SIU Manager or Fraud Specialist with providing technical guidance and advanced training to claims personnel in branch offices.  Ensures that investigations are conducted in accordance with company policies and objectives with due regard to applicable rules and regulations required under the insurance and labor laws, and civil and criminal codes of the applicable State and the United States Government. 


 


Job Specifics


Investigates cases assigned and/or identified in all areas of fraudulent or questionable activity relating to the claim, provider and underwriting operations within Zenith.

Working with claim examiners, identifies suspected fraudulent activity and develops and follows through with an investigative action plan to mitigate the claim and/or submit the investigation to law enforcement pursuant to state laws.

Responsible for management of cases assigned; identification of new and potential cases through file review; evaluation of new claims and claim trends; analysis of positive surveillance video and subsequent utilization of the video in the claims and legal process.

Establishes an investigation plan with the SIU Manager and conducts full and complete investigations relating to fraud and abuse in workers? compensation.  Investigations will include those conducted by telephone, in writing and in person within the guidelines of the published performance standards.

Prepares and provides written and oral communications concerning assigned investigations which may include, but are not limited to, investigative and prosecutorial reports, affidavits, depositions and briefings for management personnel and for potential use in legal testimony.

Demonstrates a strong knowledge of interviewing skills, particularly relating to recorded and written statements obtained from applicants, witnesses, medical providers and attorneys.  Identifies issues, obtains relevant information, secures evidence and establishes and maintains chain of custody.

Responsible for the management of investigative cases and assignments.  Investigates and concludes cases requiring specialized in-depth knowledge due to size, complexity or sensitivity.

Demonstrates a strong knowledge of workers? compensation crime statutes, workers' compensation laws, civil (tort) and criminal law related to claims.  Possesses skills in legal research to identify and apply applicable code sections to investigations.  Demonstrates a strong knowledge of settlements and negotiations and skills relating to conflict and confrontation control management.

Demonstrates a knowledge of laws pertaining to medical billing, treatment, procedures and fraudulent activity relating to the above.

On a continuing basis, develops and maintains effective contact with outside sources, and business individuals.  These contacts may include law enforcement groups and other community members who may assist in the accomplishment of Zenith investigative objectives and goals.

When directed by the Healthcare Investigation Team, or pursuant to policy and procedures, investigate medical fraud, questionable medical providers, medical management companies and other providers of medical treatment, equipment or testing.

Assists in the identification of premium fraud, premium avoidance and works closely with underwriting and premium audit to assist in the identification and investigation of these activities.

Assists in the responsibilities and participation of establishing an information database for use in conducting investigations and identifying relationships between claimants, providers and others.  Understands the costs associated to database use and demonstrates diligence in proper use of the systems. Demonstrates knowledge in the application of data analysis to detect, prevent and investigate supplier fraud.

May perform audits or evaluate findings of previous investigations conducted by SIU or outside venders.  May participate as part of a team approach on major investigations.

May participate in the identification of training needs and preparation of training programs with the Investigation Department and help develop others with the company regarding their knowledge of legal procedures and investigation techniques.  Monitors goals, projects, staff requirements, and evaluates training needs.

Evaluates and approves work performed by outside vendors.

Has an understanding of data analysis, link analysis and use of computer programs including Excel and Word.

Understands the workers? compensation, civil and criminal court systems and procedures and can work with attorneys to develop litigation strategies, deposition questions and assist with trial preparation.

Can work with people of diverse backgrounds and experience levels to develop and implement investigative action strategies in claim activities.

Performs other job related duties as assigned.


Education, Skills and Experience Requirements


College degree or equivalent business experience.  Successful law enforcement career with detective or investigative assignments may be helpful.

Must demonstrate strong analytical abilities with a minimum of 2 years combined investigation or audit/analyst experience.

Strong working knowledge of applicable insurance, civil and criminal codes, legislation, statutes, prevailing case law and Workers' Compensation claims investigative techniques.

Strong interpersonal, verbal and written communication skills.  Bi-lingual preferred.  PC literacy and experience with data base applications required. 

Excellent time management, organizational and negotiation skills. 

Valid state Driver's License in good standing. 







REF: CAAR160277

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