Regional Investigator

SUMMARY:

Responsible for investigating all aspects of workers’ compensation claims including suspicion of fraud or abuse by agents, injured workers, employers or medical providers. Develops evidentiary facts pertinent to decisions regarding compensability, revision or discontinuation of benefits, recovery of monies from an injured worker or medical provider, adjustment of prior employer reports and possible prosecution for fraud according to relevant legal statutes. Conducts various levels of investigation that may include interviews of injured workers, employers, providers or potential witnesses, obtaining various records, testifying in court, developing detailed investigative reports and preparing cases for trial. Conducts observation, evaluation and reporting of unusual or abnormal circumstances or operations at employer’s place of business or work site, whether or not related to the potential fraud under investigation.

 

PRIMARY RESPONSIBILITIES: 

· Conducts investigations to determine the legitimacy of injury and claim benefits and to recoup losses based on the liability of a third party with respect to an injury or loss.

· Interviews claimants, employers, witnesses and others to obtain statements relative to the claim presented.

· Responds to calls to the telephone fraud hotline and investigates all reports or assign to other investigators, internal or external, for follow up and reporting.

· Obtains and analyzes all documents pertaining to a particular claim or complaint.

· Conducts surveillance, follows and observes claimants to establish degree of continuing disability, including recording their activities using cameras, voice recorders and other electronic equipment, when required.

· Conducts surveillance and in-depth reviews of provider activity and billing procedures.

· Prepares and submits complete written summaries of all investigative activity and results assisting Claims Teams and Legal Department in making decisions regarding compensability of claims.

· Reviews employer classes as initially reported at policy inception for inaccuracies.

· Prepares fraud cases for prosecution, when appropriate.

· Testifies in courts of law or administrative hearings regarding investigative activities and information developed.

· Conducts Third Party investigations to recoup losses based on the liability of a third party with respect to an injury or loss.

· Reports any unusual or abnormal activities or conditions at employer’s location or work site.

· Monitors technological advances that will improve investigative or fraud outcomes and implements where appropriate.

· Identifies industry trends in workers compensation claims management related to fraud and investigations and educates Field Representatives.

· Remains current on all HIPAA changes and privacy laws that impact the AF Group workflows and communications to all appropriate parties.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

 

EMPLOYMENT QUALIFICATIONS:

A. EDUCATION REQUIRED: 

Associates degree in criminal justice, law enforcement, insurance, or a related field with progress towards or completion of investigative designations (i.e. WCCA, FCLA, FCLS). Combination of related education and experience may be considered in lieu of degree.

 

B. EXPERIENCE REQUIRED: 

Five years experience in law enforcement, or as an insurance claims investigator, insurance claims examiner, and/or an insurance claims adjustor, and a minimum of two years experience as an insurance fraud investigator.

 

C. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

· Ability to conduct surveillance from vehicles, and on foot, while maintaining a covert presence.

· Knowledge of the criminal justice system including the rules of evidence.

· Knowledge of the Michigan Workers Disability Compensation Act and other relevant civil and criminal laws.

· Knowledge of sources of information including court and other public records, computer databases, and state, local and federal offices

· Basic knowledge of word processing software and ability to prepare reports as needed.

· Ability to perform mathematic calculations to determine mileage, timelines, hour calculations, determining values for claims exposures or calculating losses for reporting of questionable claims.

· Excellent oral and written communication skills.

· Knowledge of legal and medical terminology.

· Basic knowledge of computers.

· Ability to proofread documents for accuracy of spelling, grammar