Special Investigator

This position is located in the Troy, MI office.

JOB SUMMARY: Investigates all suspicious or unlawful activity directed at policyholder and corporate assets; continually monitors and investigates suspicious external Nationwide claims and claims payment operations in pursuit of fraudulent activities and the prevention of future fraudulent payments. Reviews and recommends disposition of suspicious claims in a prompt and expeditious manner. Complies with applicable laws, regulations, company procedures, policies and objectives.

LOCATION: Property Casualty/Claims/Special Investigative Unit/Field
RELATIONSHIP: SIU Manager
DIRECT REPORTS: None

JOB RESPONSIBILITIES:
1.
Investigates assigned claims suspected of insurance fraud and other irregularities; conducts timely, thorough, and accurate inquiries of the relevant facts necessary to support the Claims Investigator?s decisions. Maintains assigned claims files in a confidential manner; documents all relevant facts pertaining to those files.
2.
Ensures that assigned cases are investigated and reported back to the S.I.U. Manager within prescribed time allowance. Prepares and submits initial and follow-up reports of findings and actions taken on each assigned claim; conforms with established procedures.
3.
Keeps Claims management informed of developments that impact claims results in assigned area.
4.
Encourages and participates in open communication with all Nationwide personnel in an effort to make claims operations more efficient and effective. Provides factual information gathered in an investigation to underwriting for purposes of evaluating risk.
5.
Maintains and fosters the best possible relationship with the general public with special emphasis towards the following groups: policyholders, claimants, agency force, attorneys-at-law.
6.
Develops and maintains a high degree of rapport and cooperation with federal, state and local governmental agencies as well as private information bureaus that can assist in investigative efforts. Participates in professional organizations.
7.
Testifies in civil and criminal courts.
8.
Maintains and pursues technical competency within area of specialization by attending insurance fraud seminars and other company-sponsored courses.
9.
Maintains all assigned company equipment. Submits expense reports and other administrative reports as required.
10.
Performs other duties as assigned.

JOB REQUIREMENTS:
Education/Knowledge: Undergraduate studies in insurance, criminal justice, law, medicine, or business. Pursuit of other claims/insurance-related courses preferred. Business/insurance operations; policy coverages and provisions. Claims handling and payment processes and procedures; technical claims investigative techniques. Familiarity with legal/judicial system?s rules and regulations as well as criminal/civil law preferred.

Experience: Three years experience in Special Investigative Unit or law enforcement work related to economic crime investigations.

Addendum
For New York operations, this addendum supersedes the education and work experience requirements listed above for SlU Investigator II, in compliance with New York CLS Ins ? 409(b)(3) and Regulation 95 (11 NYCRR ? 86.6(c)):
Persons employed by Special Investigations Units as investigators shall be qualified by education and/or experience, which shall include: an associate?s or bachelor?s degree in criminal justice or a related field; or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; or seven years of professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims.

Skills: Oral and written communication skills used to interact with all levels internal/external contact. Ability to manage large case loads. Ability to evaluate and make decisions regarding problem situations; set priorities/adapt to multiple demands with minimal supervision. Ability to operate personal computer and applicable Special Investigative Unit, claims and business software.

Staffing exceptions to the above minimum job requirements must be approved by: SIU Director, HR Consultant

JOB CONDITIONS:
Overtime Eligibility: Not Eligible (Exempt).
Working Conditions: Normal office environment. Travel required. May be exposed to potentially hazardous situations.

ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.


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