Medical Fraud Investigator

Diamond Bar, California

Company Information
Solid reputation, passionate people and endless opportunities. That's Travelers. 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.

Job Summary
Under general supervision, this position is responsible for conducting medical investigations (locally or nationally) in multiple lines of business including: Auto, General Liability and Workers Compensation. Provides investigative expertise to detect and deter medical fraud and create awareness in order to limit exposure to the company and our customers. Focus is directed towards multiple complex case investigations with regional and national implications. This job does not manage staff.

Primary Job Duties & Responsibilities
Analyzes and summarizes highly technical information related to multiple complex case investigations with regional and national implications. Conducts thorough and timely complex field investigations while managing resources with a focus on uncovering potential fraudulent medical aspects of a claim. Applies the techniques of critical thinking to prioritizes and develop medical investigations that have complex allegations and/or significantly financial impact to multiple claims and/or organized ring activity spanning across multiple lines of business and potentially across several states. Makes key decisions regarding the structure and organization of major medical case investigations involving multiple claims and/or organized ring activity with regional and national implications. Provides exceptional customer service by maintaining contact with business partners, customers and external resources throughout the life of each investigation. Acts as a liaison with local/state/federal law enforcement personnel, industry advocates and other companies Serves as the subject matter expert (liaison) on medical fraud to business and industry partners. Applies rules of evidence; recognizes evidence and determines its value to specific claim, evidence collection and interpretation. Establishes and maintains a professional network in the medical anti-fraud industry (e.g., National Insurance Crime Bureau, National Healthcare Anti-Fraud Association, local fraud agencies, law enforcement, etc.). Identifies cases for potential insurance fraud prosecution and submits questionable claims to the National Insurance Crime Bureau. Analyzes, transforms and conveys emerging trends in the medical fraud arena into actionable investigative strategies. Proactively collaborates with supporting business partners (e.g., claim, legal, nurses, analytical unit etc.) to implement anti-fraud and medical defense strategies. Responsible for strengthening technical capabilities within claim to identify potential medical fraud. Assists in the identification and communication of trends to manager of the program. Conducts post-mortems on cases closed or status reviews of cases in progress. Prepares and conducts technical training in detecting and applying techniques to multiple medical complex cases. Testifies to findings. Other duties as assigned.

Minimum Qualifications
A minimum five years of medical investigations experience or a minimum of five years medical experience required. Valid driver's license required.

Education, Work Experience & Knowledge
Bachelors degree preferred.

Job Specific & Technical Skills & Competencies
Analytical skills and ability to make deductions; logical and sequential thinker: Advanced. Analytical and problem solving skills to use and interpret information and facts as well as apply critical techniques to investigative process: Advanced. Effective business communication skills (Written & Verbal): Advanced. Computer literate; database, Internet and social media proficient: Advanced. Interviewing skills: Advanced. Computer literate; database and internet emerging social media use/search proficiency: Advanced. Conflict management skills to deal with crisis situations, hostile witnesses, etc.: Advanced. Must be a self-motivated individual: Intermediate. Excels at working independently, while making decisions to successfully pursue medical insurance fraud through establishing significant facts while preserving material that leads to the resolution of the investigation: Intermediate. Knowledge of available resources (internal and external) to assist in investigations: Advanced. Working level knowledge of insurance and claim operations, Commercial Lines, Personal Lines, and Workers Compensation insurance products: Intermediate. Time management and accurate record keeping: Intermediate. Effective business communication skills (Written & Verbal): Advanced. Strong case management skills and the ability to manage your own work independently: Intermediate. Adapt to changes in process and shifting priorities: Intermediate. Must take ownership/initiative; significant planning and goal setting skills required: Intermediate. Presentation and training skills: Intermediate. Understanding of claim best practices: Intermediate. Leadership, including delegation and ability to get work done through others: Intermediate. Influence and conflict management skills: Intermediate.

Environmental/Work Schedules/Other
Work Schedules Overnight work hours: Occasionally. Other Travel: Frequently. Incumbents who fill this position will be subject to periodic post-hire criminal background checks while employed in this position. As a condition of acceptance for the position, selected candidates for this position will be required to electronically accept the Fair Credit Reporting Act (FCRA) Disclosure Statement and Authorization included in the online employment application. You may also be subsequently asked to accept similar FCRA authorizations periodically throughout your employment with the Company.

Physical Requirements
Operates standard office equipment: Frequently. Sitting (can stand at will): Continuously. Standing: Occasionally. Lifting items up to 20 pounds: Occasionally. Use of Keyboards, Sporadic 10-Key: Frequently. Driving: Frequently.

Equal Employment Opportunity Statement
Travelers is an equal opportunity employer.
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About Travelers

The Travelers Companies, Inc. (NYSE: TRV) is a leading property casualty insurer selling primarily through independent agents and brokers. The company's diverse business lines offer its global customers a wide range of coverage in the auto, home and business settings. A component of the Dow Jones Industrial Average, Travelers has more than 30,000 employees and generated revenues of approximately $25 billion in 2010.