While the primary focus of the ISU Specialist is the development and management of ISU investigations, this position will also be responsible for managing and coordinating the investigation related processes to service the brand book of business. The position will handle individual and multi-case investigations while building the ISU capabilities for the brand. This includes: the ISU referral process, monitoring external investigation vendors, and providing direction for additional investigation opportunities. This position is responsible for fraud investigations, fraud compliance, anti-fraud training, and ISU quality assurance. The ISU Specialist examines reports, reviews video, and invoices for accuracy. Additional responsibilities include: development and implementation of medical provider investigation program. The position requires the ability to conduct investigations and perform local field investigations as needed. The ISU Specialist is responsible for client marketing of the Company's ISU capabilities and effectiveness and providing training to internal and external customers.
Ensures appropriate vendor management occurs to support the brand's business needs.
Communicates and collaborates with all of the various brand departments/teams with whom the customer may interact or impact through daily processes.
Analyze intelligence information and make determination for further investigation utilizing available resources.
Conducts computer (desk investigations) and field investigations
Develops, produces and maintains medical provider investigations
Develops and implements quality improvement and process changes to achieve greater efficiencies in the ISU department.
Develops and maintains relationship with investigations vendors.
Assists in developing the ISU annual budget, monitors budget activity, and identifies budget needs and discrepancies. Researches the causes of discrepancies and makes recommendations for remediation as necessary.
Direct, communicate, assign and manage work referred to investigations vendors.
Consistently monitors workflows to maximize efficiency. Maintains and acceptable level of service and customer satisfaction and retention.
Monitor vendor performance standards and service levels. May make recommendations for metrics used to measure vendor performance.
Analyzes trends and completes comprehensive and detailed reports.
Reconcile vendor billing and follow up with accounts payable/vendors regarding vendor accounting issues.
Evaluates training needs and designs and develops training modules, materials and evaluations related to fraud for internal and external customers as needed.
Maintains up-to-date technical knowledge of investigative core functions.
Deliver presentations as needed.
Use independent judgment in all areas of responsibility, while considering department and division priorities.
Coordinates with enterprise companies in the development and management of ISU.
Additional duties as assigned.
This position description identifies the responsibilities and tasks typically associated with the performance of the job. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS:
EDUCATION OR EQUIVALENT EXPERIENCE:
Bachelor's degree in business, criminal justice, law enforcement, insurance, or related field of education required. Knowledge of insurance fraud and other relevant civil and criminal laws is preferred. An equivalent combination of education and experience may be considered in lieu of degree, preference given to degree. Continuous learning required, as defined by the Company's learning philosophy. Certification, or progress toward, highly preferred and encouraged.
With proper education credentials, minimum of seven years of law enforcement and/or insurance claims investigations required. Workers compensation experience and/or experience in a property/casualty insurance organization preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Strong interpersonal and superior communication skills, including verbal and professional writing, report preparations and presentations.
Demonstrated leadership abilities.
Strong knowledge of laws, regulations, and compliance requirements related to insurance.
Demonstrated technical knowledge of insurance administration, claims management, or relevant insurance expertise.
Strong background in word processing, spreadsheets, and graphics programs required with knowledge of Microsoft applications preferred.
Ability to analyze and interpret documents for accuracy in reference to technical, legal and financial information.
Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate, both in oral and written communications.
Ability to quickly make decisions and comprehend the consequences of various problem situations and take appropriate actions and/or refer problems for necessary decision making.
Ability to organize and prioritize multiple assignments.
Ability to maintain confidentiality,
Ability to perform other assignments at locations outside the office.
Ability to work with minimal supervision.
Work is performed in an office setting with no unusual hazards. Travel required. Must possess a valid driver's license with a record that meets corporate standards.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.