SIU Investigation Adjuster Consultant II

About This Role

Investigate and analyze complex, multi-discipline coverage and claims referred to the Special Investigation Unit (SIU) for potential fraud. This role involves thorough investigations, including background searches, scene investigations, clinic inspections, and recorded statements, to determine if fraud can be substantiated.

Responsibilities

• Enter SIU claim data information into multiple SIU systems
• Review investigations with fraud outcomes to validate whether denial is appropriate
• Update files with investigation outcomes and return files to MCO for further handling if no fraud or insufficient evidence is found
• Conduct complex online data application searches, research, and evaluation
• Conduct complex site inspections, including body shops, medical clinics, and loss locations
• Conduct thorough investigations of complex, potentially fraudulent claims to determine if payment is warranted, including scene investigations and surveillance as needed
• Validate that information provided and obtained through investigation is true and accurate, following up on all possible leads
• Summarize documents and enter into claim system notes, documenting a claim file with notes, evaluations, and decision-making processes
• Utilize analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of fraud and damages
• Research and respond to complex customer communications, concerns, conflicts or issues

Requirements

• 3+ years of previous SIU experience
• Previous experience reviewing medical information and/or handling provider investigations

Qualifications

• 3+ years of previous SIU experience

Nice to Have

• Texas Adjuster License

Skills

* Required skills

Benefits