Director, Special Investigations Unit

📋 Description

• Develop and implement a comprehensive enterprise Special Investigations Unit (SIU) strategy to identify, investigate, and prevent insurance fraud.

• Stay informed on emerging fraud schemes and industry developments to enhance detection capabilities proactively.

• Lead and oversee SIU investigators, 1099 contractors, Field Investigators, and vendors, while setting performance expectations and key performance indicators (KPIs).

• Conduct regular performance evaluations of SIU personnel to ensure compliance with quality service standards.

• Direct investigations into suspected fraudulent activities across workers’ compensation, liability, property, casualty, and disability claims.

• Ensure that investigations adhere to company quality standards, regulatory guidelines, and evidentiary requirements.

• Review investigation outcomes and reports, and authorize referrals to law enforcement or regulatory agencies.

• Collaborate with legal teams on litigation support, depositions, and efforts related to fraud prosecution.

• Ensure adherence to state insurance fraud regulations, reporting obligations, and anti-fraud strategies.

• Maintain policies, standard operating procedures (SOPs), and training programs in line with regulatory requirements and industry best practices.

• Leverage predictive analytics, claims data mining, and external fraud databases (e.g., ISO, NICB).

• Identify high-risk claims patterns and coordinate fraud prevention initiatives with claims leadership.

• Assist leadership as needed in implementing technology and automation to enhance investigation efficiency and case results.

• Collaborate with claims, underwriting, legal, compliance, and audit teams to spot fraud indicators.

• Cultivate relationships with law enforcement, regulatory bodies, and industry fraud networks as necessary.

• Represent the organization in fraud task forces, industry associations, and regulatory meetings as required.

⛳️ Requirements

• 8–12+ years of experience in insurance claims or fraud investigation.

• 5+ years of leadership experience managing SIU or fraud investigation teams.

• A Bachelor’s degree in Criminal Justice, Insurance, Risk Management, or a related field is preferred.

• Strong knowledge of insurance fraud laws and regulatory compliance requirements.

• Proven experience in leading complex fraud investigations and providing litigation support.

• Certification as a Fraud Examiner (CFE) is preferred.

• Certification as an Insurance Fraud Investigator (CIFI) is preferred.

• A background in law enforcement or investigative work is preferred.

• Experience in workers’ compensation, casualty, or liability investigations is preferred.

🏝️ Benefits

• Medical, dental, and vision plans to support your health and that of your family.

• A 401(k) plan with employer matching.

• Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees.

• Paid holidays.

• Life insurance along with short-term and long-term disability coverage.