SIU - Senior Investigator

ICW Group

Remote, CA(remote)

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JOB DETAILS

SALARY

$78,678.61–$132,686.15 Per Year

SKILLS

Accounting, Analysis Skills, Billing, Billing Records, Case Management, Certified Financial Examiner (CFE), Claims Management, Claims Processing, Computer Skills, Copying Machines, Criminal Justice, Data Analysis, Data Sets, Detail Oriented, Develop Methodologies, Documentation, Driver's License, Fraud Investigation, Healthcare Providers, Information Technology & Information Systems, Insurance, Insurance Regulations, Interviewing Skills, Investigative Reports, Law Enforcement, Legal, Medical Billing, Medical Treatment, Microsoft Office, Microsoft Outlook, Office Equipment, Organizational Skills, Physical Demands, Presentation/Verbal Skills, Regulations, Regulatory Requirements, Relationship Management, Risk, Social Media, Surveillance, Time Management, Trend Analysis, Writing Skills

LOCATION

Remote, CA

POSTED

23 days ago

Are you looking to make an impactful difference in your work, yourself, and your community? Why settle for just a job when you can land a career? At ICW Group, we are hiring team members who are ready to use their skills, curiosity, and drive to be part of our journey as we strive to transform the insurance carrier space. We're proud to be in business for over 50 years, and its change agents like yourself that will help us continue to deliver our mission to create the best insurance experience possible. Headquartered in San Diego with regional offices located throughout the United States, ICW Group has been named for ten consecutive years as a Top 50 performing P&C organization offering the stability of a large, profitable and growing company combined with a focus on all things people. It's our team members who make us an employer of choice and the vibrant company we are today. We strive to make both our internal and external communities better everyday! Learn more about why you want to be here! **PURPOSE OF THE JOB** The Senior Special Investigation Unit (SIU) Investigator works to detect, prevent, and investigate suspected fraudulent claims for all lines of insurance, with focus aligned to enterprise risk priorities. This position exists to protect company assets through examining potential fraudulent cases. The work is aligned to either Desk or Field investigative assignments. **ESSENTIAL DUTIES AND RESPONSIBILITIES** **Leads Complex and Major Case Investigations** + Conducts advanced, large-scale investigations involving organized fraud rings, provider fraud schemes, (medical, legal, and ancillary services), referral/kickback schemes. + Identifies patterns of coordinated activity across multiple claims to detect systemic and enterprise-level fraud risks. + Independently manages complex, multi-jurisdictional cases from inception to resolution. + Interviews claimants, witnesses, employers, medical providers, and legal representatives, utilizing advanced interviewing and interrogation techniques. + Develops and secures recorded statements, affidavits, and evidence to support investigative findings. + Performs on-site investigations, clinic inspections, and surveillance coordination as appropriate. **Data Analysis & Intelligence Development** + Interprets and synthesizes large volumes of data from multiple sources, including claims systems, billing records, social media, and third-party databases. + Identifies anomalies, trends, and networks/relationships indicative of fraud through link analysis and data correlation. + Develops actionable intelligence packages to support internal stakeholders and external enforcement actions. **Provider & Organized Fraud Focus** + Identifies and investigates fraud involving service providers, legal entities, and billing schemes, including upcoding, billing irregularities, and treatment patterns inconsistent with injuries. + Coordinates with internal and external experts to evaluate medical necessity, treatment patterns, and provider networks. **Fraud Detection & Case Development** + Evaluates referrals for fraud indicators and determines appropriate investigative strategies. + Builds comprehensive case files supported by well-documented evidence, timelines, and investigative summaries. + Ensures all findings meet standards required for regulatory reporting, civil litigation, and criminal prosecution. **Collaborates with Legal & Regulatory Entities** + Partners closely with law enforcement, district attorneys, regulatory agencies, and legal counsel to advance cases. + Presents investigative findings in a professional manner for case review, prosecution, or civil recovery actions. + Maintains detailed knowledge of relevant laws, regulations, and evidentiary standards. **Case Management & Reporting** + Produces clear, concise, and defensible investigative reports covering all aspects of the case lifecycle. + Maintains accurate documentation in case management systems and ensures timely progression of cases. **SUPERVISORY RESPONSIBILITIES** This role does not have supervisory responsibilities. **EDUCATION AND EXPERIENCE** Bachelor’s degree with a major in Criminal Justice, Business, Accounting, Information Systems, or closely related (or an equivalent combination of education/experience). Minimum of 5 years’ related work experience required. The Senior SIU Field Investigator requires experience specifically in investigations and/or law enforcement. **CERTIFICATES, LICENSES, REGISTRATIONS** Private Investigator's License or fraud related certificates (CFE, CIFI) preferred. Requires valid Driver’s license. **KNOWLEDGE AND SKILLS** + Good computer skills in Microsoft Office/Outlook and expertise using investigative case management software/tools (such as Polonious or similar) + Experience with case management systems and investigative tools + Fundamental knowledge of claims management processes and claims handling + Knowledge of Unfair Claims Practices Act, Legislative, and Insurance Department regulatory requirements + Familiarity with civil/criminal investigation procedures and the legal system + Demonstrated experience with managing relationships to complete thorough investigations + High level of critical thinking, attention to detail, and independent judgment + Excellent written/verbal and presentation skills + Experience with advanced investigative and interviewing skills + Ability to analyze and interpret large, complex data sets + Strong knowledge of fraud schemes, claims handling, legal procedures, and medical / services billing + Ability to present information within a courtroom setting **PHYSICAL REQUIREMENTS** Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear. **WORK ENVIRONMENT** This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment. We are currently not offering employment sponsorship for this opportunity. #LI-JM1 #LI-Remote The current range for this position is $78,678.61 - $132,686.15 This range is exclusive of fringe benefits and potential bonuses. If hired at ICW Group, your final base salary compensation will be determined by factors unique to each candidate, including experience, education and the location of the role and considers employees performing substantially similar work. **WHY JOIN ICW GROUP?** + Challenging work and the ability to make a difference + You will have a voice and feel a sense of belonging + We offer a competitive benefits package, with generous medical, dental, and vision plans as well as 401K retirement plans and company match + Bonus potential for all positions + Paid Time Off + Paid holidays throughout the calendar year + Want to continue learning? We’ll support you 100% _ICW Group is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer. ICW Group will not discriminate against an applicant or employee on the basis of race, color, religion, national origin, ancestry, sex/gender, age, physical or mental disability, military or veteran status, genetic information, sexual orientation, gender identity, gender expression, marital status, or any other characteristic protected by applicable federal, state or local law._ **At ICW Group we offer a work environment that encourages entrepreneurialism and celebrates success. Our team members are hands-on contributors who are given the opportunity to make an impact. It's our people who make us an employer of choice and the vibrant company we are today.** **Job Category:** **Claims** **Job Type:** **Full time** **Req ID:** **JR101487**

About the Company

ICW Group

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