Senior Investigator

This is a fully remote position, open to applicants in California.

📋 Description

• Oversees intricate and significant case investigations.

• Conducts sophisticated, large-scale inquiries involving organized fraud rings, provider fraud schemes (medical, legal, and ancillary services), and referral/kickback schemes.

• Detects patterns of coordinated activity across multiple claims to uncover systemic and enterprise-level fraud risks.

• Manages complex, multi-jurisdictional cases independently from start to finish.

• Conducts interviews with claimants, witnesses, employers, medical providers, and legal representatives, employing advanced interviewing and interrogation techniques.

• Collects and secures recorded statements, affidavits, and evidence to bolster investigative findings.

• Executes on-site investigations, clinic inspections, and coordinates surveillance as necessary.

• Analyzes and synthesizes large amounts of data from diverse 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.

• Creates actionable intelligence packages to aid internal stakeholders and support external enforcement actions.

• Assesses referrals for fraud indicators and formulates suitable investigative strategies.

• Constructs comprehensive case files backed by meticulously documented evidence, timelines, and investigative summaries.

• Ensures all findings comply with standards necessary for regulatory reporting, civil litigation, and criminal prosecution.

• Collaborates closely with law enforcement, district attorneys, regulatory agencies, and legal counsel to propel cases forward.

• Presents investigative findings professionally for case reviews, prosecutions, or civil recovery actions.

• Maintains a thorough understanding of pertinent laws, regulations, and evidentiary standards.

• Produces clear, concise, and defensible investigative reports encompassing all facets of the case lifecycle.

• Keeps accurate documentation in case management systems and ensures timely advancement of cases.

⛳️ Requirements

• Bachelor’s degree in Criminal Justice, Business, Accounting, Information Systems, or a closely related field (or a combination of education and experience equivalent).

• At least 5 years of relevant work experience is required.

• Senior SIU Field Investigator role necessitates specific experience in investigations and/or law enforcement.

• A Private Investigator's License or fraud-related certifications (CFE, CIFI) are preferred.

• A valid Driver’s license is required.

• Proficient computer skills in Microsoft Office/Outlook and expertise in using investigative case management software/tools (such as Polonious or similar) are necessary.

• Experience with case management systems and investigative tools is essential.

• Fundamental knowledge of claims management processes and claims handling is required.

• Understanding of the Unfair Claims Practices Act, legislative, and insurance department regulatory requirements is needed.

• Familiarity with civil/criminal investigation procedures and the legal system is advantageous.

• Proven experience in managing relationships to facilitate thorough investigations.

• High level of critical thinking, attention to detail, and independent judgment is expected.

• Excellent written, verbal, and presentation skills are necessary.

• Experience in advanced investigative techniques and interviewing skills is essential.

• Ability to analyze and interpret large, complex data sets is required.

• Strong knowledge of fraud schemes, claims handling, legal procedures, and medical/services billing is essential.

• Capability to present information in a courtroom setting.

🏝️ Benefits

• Health insurance.

• 401K retirement plans with company match.

• Paid Time Off.

• Paid holidays throughout the year.

• Support for professional development.