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Under minimal direction, initiates and manages suspected provider fraud investigations (medical, legal, etc.) involving the highest complexity matters specifically within California. This role requires knowledge of complex fraud schemes and emerging trends, a solid understanding of law enforcement processes and reporting requirements, and the ability to testify credibly when called upon to do so. The investigator should possess solid analytical skills and have an in-depth knowledge of the fraud schemes prevalent in California, as well as a working knowledge of state regulations, B&P Codes, CPT Codes, and other applicable tools necessary to investigate fraud. Preferably, the candidate also possesses a strong knowledge of Qui Tam litigation, lien consolidations, and other civil remedies that may be employed. Provides advice, direction, and support to technical claim team and counsel on the detection, investigation, and litigation of suspected claims.
This position works from our office in a hybrid capacity from one of our CA offices in Walnut Creek, Los Angeles, Brea, Irvine or San Diego.
JOB DESCRIPTION:
Essential Duties & Responsibilities
Performs a combination of duties in accordance with departmental guidelines:
- Leads the detailed analysis and completion of thorough and timely investigations of suspected claim fraud by following Best Practice Guidelines and collaborating with insureds, claimants, witnesses and experts.
- Develops and executes investigation strategy either independently or in collaboration with claim professionals, counsel, experts, insureds, and other stakeholders.
- Manages investigation activities independently and/or coordinates/oversees vendor service partner activities in the field.
- Maintains detailed, accurate and timely case records by following established Best Practices for file documentation and by creating comprehensive reports of investigative findings, and conclusions.
- Makes recommendations for claim resolution by presenting findings and proposing solutions of moderate to complex scope.
- Identifies opportunities and participates in the design and implementation of process or procedural improvements.
- Leads or directs efforts to build and enhance and oversees organizational capabilities by developing and delivering fraud awareness or regulatory compliance training and mentoring lower SIU staff.
- Leads or directs the preparation of cases for presentation to outside agencies,; leads or directs pursuit of criminal or civil actions through gathering and documenting relevant data, organizing and summarizing facts and testifying on behalf of the company in civil or criminal matters.
- Continuously develops knowledge and expertise related to insurance fraud by keeping current on related law, regulations, trends, and emerging issues and participating in insurance fraud or related professional associations.
Reporting Relationship
Typically Manager or Director
Skills, Knowledge and Abilities
- Advanced knowledge of property and casualty claim handling practices
- Superior or expert technical knowledge of practices and techniques related to investigations and fact finding
- Excellent interpersonal, oral, and written communication skills; ability to synthesize and communicate complex issues to all levels within the organization
- Excellent ability to interact and collaborate with internal and external business partners, including outside agencies
- Proven ability to work independently, exercise good judgment, make sound business decisions, and develop others
- Highly organized and detail oriented with strong time management skills
- Proven ability to analyze highly complex, ambiguous problems and to develop and implement effective solutions
- Proficiency with Microsoft Office applications and similar business software, and understanding of relational databases information querying techniques
- Ability to lead change while valuing diverse opinions and ideas
- Ability to implement proactive, long term strategies in support of business objectives.
Education and Experience
- Bachelor’s degree or equivalent professional experience; advanced degree highly desired.
- Minimum of eight (8) years of experience conducting or directing investigations in the area of a) insurance fraud, b) law enforcement, c) civil or criminal litigation, or d) similar field.
- Professional certification or designation related to fraud investigations strongly preferred (e.g., CFE, CIFI, FCLS, FCLA, or similar).
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In certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In District of Columbia, California, Colorado, Connecticut, Illinois, Maryland, Massachusetts, New York and Washington, the national base pay range for this job level is $72,000 to $141,000 annually. Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees – and their family members – achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA’s benefits, please visit cnabenefits.com.
CNA utilizes AI-enabled technology during the recruiting process. For more information, please visit our careers page.
CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact leaveadministration@cna.com
