Job Description

While the primary focus of the SIU Specialist is the development and management of vendor‑conducted SIU investigations, this position is primarily responsible for managing surveillance and other investigations for California claims while also coordinating investigation‑related processes to service the brand book of business. A high level of knowledge of California laws, regulations, and Department of Insurance (CDI) requirements required to ensure all investigative activity is legally compliant.

The position will handle individual and multi‑case investigations while building the SIU capabilities for the brand. This includes the SIU referral process, monitoring external investigation vendors, and providing direction for additional investigation opportunities. This position is responsible for fraud investigations, California‑specific SIU compliance and annual regulatory reporting, anti‑fraud training, and SIU quality assurance. The SIU Specialist examines reports, reviews video, and invoices for accuracy.

Additional responsibilities include development, oversight, and implementation of medical provider fraud investigations. The position requires the ability to conduct investigations and vendors manage field investigations as needed. The SIU Specialist is responsible for internal and external education regarding the Company’s SIU capabilities and effectiveness, including training and mentoring teammates.

RESPONSIBILITIES / TASKS:

• Ensures appropriate vendor management occurs to support the brand’s business needs.
• Communicates and collaborates with all brand departments and teams impacted by investigative activity.
• Analyze intelligence information and make determinations for further investigation utilizing available resources.
• Conducts computer (desk investigations) and manage vendor field investigations.
• Develops, produces, and maintains medical provider investigations.
• Develop and implement quality improvement and process changes to achieve greater efficiencies in the SIU Department.
• Develops and maintains relationships with investigations vendors.
• Assists in developing the SIU annual budget, monitors budget activity, and identifies discrepancies; research causes and recommends remediation. Research the causes of discrepancies and makes recommendations for remediation, as necessary.
• Direct, communicates, assigns, and manages work referred to investigation’s vendors.
• Consistently monitors workflows to maximize efficiency while maintaining acceptable service levels and customer satisfaction.
• Monitor vendor performance standards and service levels may make recommendations for metrics used to measure vendor performance.
• Analyzes fraud trends and completes comprehensive and detailed reports.
• Reconciles vendor billing and follow up with accounts payable/vendors regarding vendor accounting issues.
• Prepares and supports annual SIU compliance activities, including California Department of Insurance reporting and audits.
• 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 and California regulatory changes.
• 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 SIU.
• 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.

EXPERIENCE:

With proper education credentials, minimum of seven years of law enforcement and/or insurance claims investigations is required. Workers’ compensation experience and/or experience in a property/casualty insurance organization preferred.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

1. Strong interpersonal and superior communication skills, including verbal and professional writing, report preparations, and presentations.

2. Demonstrated leadership abilities.

3. Strong knowledge of laws, regulations, and compliance requirements related to insurance.

4. Demonstrated technical knowledge of insurance administration, claims management, or relevant insurance expertise.

5. Strong background in word processing, spreadsheets, and graphics programs required with knowledge of Microsoft applications preferred.

6. Ability to analyze and interpret documents for accuracy in reference to technical, legal, and financial information.

7. 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.

8. 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.

9. Ability to organize and prioritize multiple assignments.

10. Ability to maintain confidentiality,

11. Ability to perform other assignments at locations outside the office.

12. Ability to work with minimal supervision.

WORKING CONDITIONS:

Work performed in an office setting with no unusual hazards and/or remotely. Minimal travel required. Must possess a valid driver’s license with a record that meets corporate standards. Work may be needed during different hours throughout the day, and occasionally, weekend shifts might be necessary.

PAY RANGE:

Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other potential factors. It is not the standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $73,600 and $123,200.

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. 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.

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