Job Description
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. Claims investigated are primarily for accident insurance and health insurance policies. The individual performs a thorough investigation including:
(1) conducting background searches, scene investigations, and clinic inspections
(2) taking recorded statements
(3) reviewing and analyzing medical notes, bills and property damage; and conducting witness interviews and social media searches. The individual reviews whether fraud can be substantiated and supports a lawsuit.
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
• 3+ years of investigative experience (Preferred)
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Skills
Claims Processing, Critical Thinking, Fraud Investigations, Information Collection, Insurance, Insurance Investigation, Process Improvements, Special Investigations
Compensation
Compensation offered for this role is 68,500.00 - 115,600.00 annually and is based on experience and qualifications.
The candidate(s) offered this position will be required to submit to a background investigation.
Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs.
When working from home, you must have a dedicated, private workspace free from distractions, along with appropriate desk and seating. Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.
To help create a more personal and engaging experience, we ask that you join with your camera on if your interview is virtual. Please also have a Valid Photo Identification available at the start of your interview. If you require any accommodations or have questions ahead of your interview please reach out to your recruiter.
Note: Internal candidates are only asked to join on video; a Valid Photo Identification is not needed for the interview.
