<p>The SIU team is currently seeking an SIU Specialist. This is a full-time, exempt position with a remote or hybrid work schedule seated in one of our Claims offices. Travel may be required.</p> <p>POSITION OVERVIEW:</p> <p>The SIU Specialist is responsible for leading and executing investigations into suspected fraud across medical, major case, and underwriting domains. This role will target Medical claims to ensure compliance with regulatory standards, supports litigation efforts, and collaborates with internal and external stakeholders to mitigate risk and uphold ethical claims practices.</p> <p>IN THIS ROLE, YOU WILL:</p> <ul> <li> <p>Supervise, coordinate and monitor activities of medical fraud investigations in order to obtain and ensure an accurate, quality product while maintaining high production and performance standards.</p> </li><li> <p>Evaluate and give guidance to investigators on an ongoing basis.</p> </li><li> <p>Coordinate and act as a liaison with other departments in which SIU interacts.</p> </li><li> <p>Recommend procedural changes, plan, organize and implement the changes under SIU leadership guidance.</p> </li><li> <p>Ensure proper reporting to appropriate state and fraud prevention agencies in accordance with company policy and regulatory requirements.</p> </li><li> <p>Research and analysis of complex medical investigations involving claims for all lines of business.</p> </li><li> <p>Provide continuing education on SIU initiatives to other departments.</p> </li><li> <p>Position to target assignments generated from fraud models: MedSentry, ABI, WC and CGL.</p> </li><li> <p>Additional oversight on NICB alerts, ForeWarns, AMD's, Strategic Alerts.</p> </li><li> <p>Target states with low penetration rates to drive diversification.</p> </li><li> <p>Leverage/manage field staff for RS, scene work ups, witnesses canvassing, clinic visits.</p> </li><li> <p>Supervise, coordinate and monitor activities of medical fraud investigations conducted by field personnel and management of approved PI vendors.</p> </li><li> <p>Research and analysis of complex medical investigations involving claims for all lines of business in the casualty and specialized response teams.</p> </li><li> <p>Evaluate and give guidance to desk/field investigators.</p> </li><li> <p>Coordinate and act as a liaison with local, state, and federal medical fraud task forces that includes Medicare/Medicaid groups (attends meetings that drive referrals for trends/schemes identified by these task forces).</p> </li><li> <p>Ensure proper reporting to appropriate state and fraud prevention agencies in accordance with company policy, business expectations and regulatory requirements.</p> </li><li> <p>Provide continuing education on SIU initiatives in the medical fraud space to other departments.</p> </li></ul> <p>WHAT YOU NEED TO APPLY:</p> <ul> <li> <p>Bachelor's degree. Advanced degree preferred (e.g., nurse, medical expertise).</p> </li><li> <p>Background in the following: medical terminology, procedures, injuries and medical coding, SIU investigation and litigation.</p> </li><li> <p>Prior medical SIU background, CPC, AHFI accreditation is desired.</p> </li><li> <p>Analyze claims generating from the casualty service segment specifically claims from the SIU models for PIP, ABI, CGL and WC LOB's.</p> </li><li> <p>Provide facts/information/details to the claims handler to mitigate the claim using intel from SIU resources; MedSentry, IES, Model details, Accurint, ISO, NICB alerts, AMD alerts, SIU watchlist alerts, Fraud alerts, task force detail.</p> </li><li> <p>Aggressive learner and self-starter, committed to self-development.</p> </li><li> <p>Persistent, persevering and results driven.</p> </li><li> <p>Ability to be flexible and able to adjust to high volume environment.</p> </li><li> <p>Skilled at logical and creative thinking and ability to test information.</p> </li><li> <p>Familiarity with investigative techniques, such as interviewing and evidence collection.</p> </li><li> <p>Strong organization and communication skills.</p> </li><li> <p>Strong mentoring skills.</p> </li><li> <p>Dedicated to meeting the expectations and requirements of internal and external customers.</p> </li><li> <p>Knowledge of internal and external customer's needs and good faith claim practices.</p> </li><li> <p>Easily adapts to new, different or changing situations, requirements or priorities.</p> </li><li> <p>Ability to work independently with low dependency needs.</p> </li><li> <p>Applies knowledge of company products and processes to understand key customer issues and needs.</p> </li><li> <p>Able to provide clear and concise direction.</p> </li><li> <p>Effective analytical person, who anticipates issues, seeks out and analyzes information collaboratively to propose solutions.</p> </li><li> <p>Takes ownership for a successful resolution.</p> </li><li> <p>Possesses a strong moral and work ethic, is trustworthy and able to maintain confidentiality.</p> </li><li> <p>Low level of harm-avoidance or fear of conflict.</p> </li><li> <p>Proficient in utilizing technological systems (e.g., MS Office, excel, word, Power BI, Power Apps).</p> </li><li> <p>Polished, well-spoken, and a collaborative person with an elevated level of written and verbal communication skills.</p> </li><li> <p>Proficient in operating a personal computer and standard office equipment to complete daily responsibilities efficiently.</p> </li><li> <p>Ability to sit or stand for extended periods, depending on task requirements.</p> </li><li> <p>Flexibility to work on-site as needed, based on business priorities.</p> </li><li> <p>Willingness and ability to travel for meetings, training sessions, or operational support, as required.</p> </li><li> <p>Availability to work outside of standard business hours-including evenings or weekends-based on workload or project demands.</p> </li><li> <p>Ability to perform effectively in a fast-paced, dynamic, and occasionally high-pressure environment.</p> </li><li> <p>Comfortable working in environments with varying levels of ambient noise.</p> </li></ul> <p>This job posting provides cursory examples of some of the job duties associated with this position. The examples provided are not complete, and the position may entail other essential and job-related functions and responsibilities that employees will be required to perform.</p>