SIU Medical Provider Fraud Investigator

At Allstate, great things happen when our people work together to protect families and their belongings from life's uncertainties. And for more than 90 years, our innovative drive has kept us a step ahead of our customers' evolving needs. From advocating for seat belts, air bags and graduated driving laws, to being an industry leader in pricing sophistication, telematics, and, more recently, device and identity protection.

Job Description

This role is responsible for identifying suspicious medical provider businesses, attorneys, and law firms that may be connected for the purpose of generating fraudulent payments. The individual will conduct thorough investigations by identifying injured parties, billing trends, treatment sequences, attorney relationships, and claim reporting patterns. Responsibilities include conducting database searches, performing data mining, taking recorded statements, attending virtual depositions and mediations, and leading case investigation meetings. This role typically handles bodily injury claim files, including both non-litigation and litigation matters.

We are seeking an experienced SIU Medical Provider Fraud Investigator, preferably located within the Central Time Zone, who holds an active Texas All-Lines Adjuster License or a reciprocal state license. The ideal candidate brings a strong investigative mindset with the ability to identify suspicious patterns, conduct complex medical provider fraud investigations, and thoroughly document findings. Success in this role requires exceptional organizational skills, attention to detail, analytical thinking, and the ability to manage multiple investigations effectively. Strong written and verbal communication skills are essential, along with the ability to collaborate with internal partners and present investigative findings in a clear, concise, and professional manner.

Key Responsibilities

• Enters SIU claim data information into multiple SIU systems

• Reviews investigations with fraud outcomes to validate whether denial is appropriate

• Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement

• Conducts complex online data application searches, research, and evaluation

• Conducts complex site inspections, including body shops, medical clinics, loss locations etc.

• Conducts thorough investigations of complex that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed

• Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads

• Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process

• Utilizes analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages

• Researches and responds to complex customer communications, concerns, conflicts or issues

Supervisory Responsibilities

• This job does not have supervisory duties.

#LI-AS

Skills

Analytical Thinking, Complex Claims, Fraud Investigations, Healthcare Fraud Prevention, Insurance Claims Investigations, Insurance Fraud, Litigation, Medical Codes, Medical Malpractice, Medical Record Auditing, Witness Interviewing

Compensation

Base compensation offered for this role is:

SIU Cons I: $60,000.00 - $87,400.00/salary

SIU Cons II: $62,100.00 - $92,700.00/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.

Notice of Licensing Requirement: As a condition of employment, you are expected to satisfy licensing requirements. Failure to complete these requirements within the time frame designated by the hiring department may result in the recommendation to terminate your employment with National General Insurance, an Allstate Insurance Company. In addition, you must maintain all licensing required for your role. This includes any continuing education and/or other state-affiliated requirements for licensing renewal. Failure to retain appropriate licensing could lead to disciplinary action up to and including termination of your employment. In addition, you must agree to surrender any currently held resident license (producer or adjuster) that is inconsistent with your role at National General Insurance and terminate all non-Allstate appointments upon being hired for any role within Allstate Insurance Company.

The candidate(s) offered this position will be required to submit to a background investigation.

Joining our team isn't just a job - it's an opportunity. One that takes your skills and pushes them to the next level. One that encourages you to challenge the status quo. One where you can shape the future of protection while supporting causes that mean the most to you. Joining our team means being part of something bigger - a winning team making a meaningful impact.

Allstate generally does not sponsor individuals for employment-based visas for this position.

Effective July 1, 2014, under Indiana House Enrolled Act (HEA) 1242, it is against public policy of the State of Indiana and a discriminatory practice for an employer to discriminate against a prospective employee on the basis of status as a veteran by refusing to employ an applicant on the basis that they are a veteran of the armed forces of the United States, a member of the Indiana National Guard or a member of a reserve component.

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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.