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Under moderate direction, initiates and manages suspected fraudulent claim or provider investigations involving medium to high complexity matters within a line of business and/or geographic region. Provides advice, direction, and support to technical claim team and counsel on the detection, investigation, and litigation of suspected fraudulent claims. Roles may have a focus in an area of specialty (i.e. medical provider fraud, etc.).
JOB DESCRIPTION:
Essential Duties & Responsibilities
Performs a combination of duties in accordance with departmental guidelines:
- Conducts detailed analysis and completes thorough and timely investigations of suspected claim and/or provider fraud by following Best Practice Guidelines and collaborating with insureds, claimants, witnesses and experts.
- Develops and executes investigation strategy in collaboration with claim professionals, counsel, experts, insureds, and other stakeholders.
- Generally, manages investigation activities independently but requires guidance with unfamiliar or unusual issues; and coordinates/ oversees vendor service partner activities in the field.
- 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.
- Makes recommendations for claim and/or provider resolution by presenting findings and proposing solutions of moderate scope.
- 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.
- Participates in building and enhancing organizational capabilities by developing and participating in the delivery of fraud awareness or regulatory compliance training and mentoring lower-level SIU staff.
- 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.
- 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.
Reporting Relationship
Typically Manager or Director
Skills, Knowledge and Abilities
- Solid knowledge of property and casualty claim handling practices
- Strong technical knowledge of practices and techniques related to investigations and fact finding.
- Strong technical knowledge of respective specialty practices is required. This role will have a main focus on Commercial Auto and General Liability. With the potential to cover other lines of business.
- Strong interpersonal, oral, and written communication skills; ability to clearly communicate complex issues
- Ability to interact and collaborate with internal and external business partners, including outside agencies
- Ability to work independently, exercise good judgment, and make sound business decisions
- Detail oriented with strong organization and time management skills
- Strong ability to analyze complex, ambiguous matters and develop effective solutions
- Proficiency with Microsoft Office applications and similar business software, and understanding of relational databases information querying techniques
- Ability to adapt to change and value diverse opinions and ideas
- Developing ability to implement change
- Ability to travel occasionally (less than 10%)
Education and Experience
- Bachelor's degree or equivalent professional experience.
- Minimum of three to five years of experience conducting investigations in the area of a) insurance fraud, b) civil or criminal litigation, or c) similar field.
- Professional certification or designation related to fraud investigations strongly preferred (e.g., CFE, CIFI, FCLS, FCLA, or similar).
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I n certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In District of Columbia , California, Colorado, Connecticut, Illinois , Maryland , Massachusetts , New York and Washington, the national base pay range for this job level is $54,000 to $103,000 annually.Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees - and their family members - achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA's benefits, please visit cnabenefits.com .
CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact [email protected] .
