SIU Investigator

This job is responsible for investigating and analyzing complex and occasionally highly complex, multi-discipline coverage and claims that have been referred to the special investigation unit (SIU) for potential fraud. This role typically handles a combination of complex attorney represented and unrepresented claims and complex losses and claims involving extra-contractual liability, medical losses in which suspicious activity has been identified. The individual performs a thorough investigation including; (1) conducting background searches; (2) taking recorded statements; (3) reviewing and analyzing medical notes & bills; and (3) conducting witness interviews and social media searches. The individual reviews whether fraud can be substantiated and supports a lawsuit. We are seeking a Special Investigation Unit (SIU) Investigator to conduct in-depth investigations of accident and health insurance claims involving potential fraud. The ideal candidate brings a strong insurance claims background with experience reviewing medical claims to identify, analyze, and substantiate suspected fraudulent activity.

Key Responsibilities

• Makes claim decisions regarding complex and occasionally highly complex investigations, and pursues restitution
• Manages, researches, and resolves complex and occasionally highly complex customer communications, concerns, conflicts or issues
• Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
• Conducts thorough investigations of complex and occasionally highly complex multi-discipline claims and ECL claims that are potentially fraudulent to determine if payment is warranted
• Utilizes analytic tools or SIU field intelligence to identify complex and occasionally highly complex claims for investigation and/or for support in the evidence of the fraud and damages
• Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision making process
• Enters SIU claim data information into multiple SIU systems
• Updates files with investigation outcome, and when no fraud, or if insufficient evidence is found, returns file to MCO for further handling and settlement
• Reviews investigations with fraud outcomes to validate whether denial is appropriate
• Conducts complex and occasionally highly complex online data application searches, research, and evaluation

Supervisory Responsibilities

• This job does not have supervisory duties.

#LI-AS2 Skills Analytical Thinking, Complex Claims, Data Analytics, Documentations, Health Insurance Claims, Insurance Claims, Medical Claims, Witness Interviewing

Compensation

Base compensation offered for this role is: SIU Adjuster Cons I: $60,000.00 - 87,400.00/salary SIU Adjuster Cons II: $62,100.00 - 92,700.00/salary SIU Adjuster Sr. Cons I: $68,500.00 - 104,100.00/salary Compensation is based on experience and qualifications. Total compensation for this role may include additional components, such as incentive pay (for example, commission or bonus), if applicable. The candidate(s) offered this position will be required to submit to a background investigation. Allstate generally does not sponsor individuals for employment-based visas for this position. Apply tot his job Apply To this Job