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Job Description
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SIU Medical Fraud Investigator
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789265
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05/08/2009
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NJ-Parsippany
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Committed. Competitive. Constructing our Future.
That's Travelers. We are one of the leading insurance companies in the United States. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy, and a workplace in which you truly can make a difference.
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SUMMARY:
Position dedicated to investigation of national (country-wide) medical fraud cases to achieve results in fraudulent payout reduction.
PRIMARY DUTIES:
Primarily responsible to conduct medical fraud investigations in complex, large, geographically dispersed cases with high exposure, etc.
Forecasts needs from emerging trends in the medical fraud arena (e.g., NICB and industry alerts, leads from lines of business, etc.)
Works closely with resources outside of SIU (e.g., business partners, NICB, other insurance carriers) to maximize efficiency and performance of the program
Conducts technical training of non-dedicated medical fraud investigators to build technical capabilities to meet performance standards of the program. Provides constructive feedback and coaches as part of training efforts conducted. May conduct file reviews for quality of investigation as part of this training effort.
Responsible for building technical capabilities in Claim staff to identify potential medical fraud in claim files
Provides advice and consultation, as subject matter expert, to SIU investigators and Claim staff.
May conduct missed opportunity reviews of claim files as needed (e.g., by LOB, by emerging trends, etc.). Researches/analyzes industry trends and best practices in the medical fraud investigation discipline to maximize results. Conducts risk analysis to determine/forecast and minimize potential exposures (e.g., use of chiropractors, durable medical equipment fraud, medical office procedures/protocol).
Manages expenses to stay within dedicated medical fraud budget (e.g., travel, equipment, supplies, etc.).
Builds relationship with Claim managers and other business partners (e.g., Legal, Medical Director, nurses, etc.) to assure that priorities are being identified and addressed.
May assist Claim University to develop specific training programs/materials for the medical fraud program. Assists with marketing dedicated medical fraud unit services to business partners within and outside of Claim.
Establishes and maintains effective relationships with local/state/federal law enforcement personnel, national insurance crime bureau and local fraud agencies.
Stays knowledgeable on laws pertaining to fraud and insurance coverage.
Participates in the identification and selection of experts.
Works with attorneys to develop litigation strategies and to prepare experts to testify.
Conducts interviews, reviews documents and collects, identifies and safeguards evidence.
Develops medical fraud cases at a high level with a provider or group of providers
Utilizes SAU (e.g., link analysis, analysis of payout, identification of CPT codes, etc.)
Flags need for position papers on provider(s) and/or medical procedures
Determines which providers go into Participant Flagging System as auto referral and/or blocked payment
Works with LOB leads and Legal to develop strategies and action plans for specific geographical jurisdictions or line-specific issues
Act as liaison with other companies and their medical fraud teams
Assists in the identification and communicates of trends, makes recommendations to manager of the program. Drafts medical position papers or best practices about claim handling procedures.
Conducts post-mortems on cases closed or status reviews of cases in progress (what went well, what fell through the cracks and why, how to fix going forward).
Testifies as to findings as appropriate.
EDUCATION/COURSE OF STUDY:
Minimum 4-year college degree or equivalent law enforcement or medical fraud claim experience.
WORK EXPERIENCE:
Significant specialized expertise in detecting and investigating medical fraud schemes in a multi-jurisdictional environment utilizing various investigative techniques and strategies.
COMMUNICATION SKILLS:
Strategic communication.
Conflict management skills.
COMPUTER SKILLS:
Computer literate; database and Internet proficient
OTHER:
Knowledge of Claim, PL, CL and WC product lines.
Leadership, including delegation, organization and follow-up skills and ability to get work done through others.
Relationship management and Team Building.
Analytical Skills; problem solving and decision-making.
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Travelers is an equal opportunity employer. We actively promote a drug-free workplace.
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