Job Details

llumifin provides third party administration and technology services to individual and group insurers. The company blends insurance industry knowledge, technology leadership and operational execution to prepare insurers for the digital future.

illumifin is a diverse, passionate and empowered team of insurance specialists committed to the growth and success of its customers. With illumifin, there's a brighter future

A SIU/Fraud Investigator is responsible for working with multiple business units on coordination, identification, mitigation, and reporting of incidents and risks related to anti-fraud activities.

• Conducts and/or assists with investigative tasks
• Reviews referrals of potential fraud, waste, and abuse from both auto-detection programs and from claims organization, as assigned
• Coordinates and performs investigations with oversight of lead investigator
• Prepares responses for suspected or alleged fraud
• Works closely with cross-functional leaders to ensure appropriate resolution, accurate reporting and tracking to meet client specific service level agreements
• Participates as a subject matter expert during client implementations, audits and system or process development
• Complies with state and federal laws to meet client contractual requirements
• Conducts effective research, analysis, and accurate documentation for reporting to clients and illumifin's leadership
• Schedules surveillance once approved by the client
• Conducts continuing education to Claims staff
• May conduct phone calls or basic interviews with witnesses, as assigned
• Assists with administration tasks relating to Fraud Services Department, as assigned
• Assists with client and department reporting
• Interfaces with claimants, providers and clients
• Conducts telephonic interviews of members, providers, and/or additional witnesses to gather information to support investigation
• Other duties as assigned

Qualifications

• Bachelor's degree in criminal justice, healthcare, accounting, finance or business-related field
• 5+ years of experience in fraud investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions
• Ability to manage non-complex investigations as lead with minimum supervision or oversight
• Possesses and maintains a clear understanding of investigative techniques and the laws pertaining to insurance claims and mandated fraud reporting
• Demonstrated ability to use data to perform investigations
• Highly motivated & detail-oriented professional with excellent analytical, organizational, verbal/written communication and follow-up skills
• Skilled using Microsoft Word, Excel, Outlook, Access, PowerPoint and research tools

Preferred Qualifications

• Designations as: Certified Fraud Examiner, Health Care Anti-Fraud Associate or Long-Term Care Professional
• Working knowledge of medical terminology
• Experience in fraud detection and investigations within the long-term care or health care industry

The salary range starts at $60,000 for this position. If the candidate qualifies for a senior level role adjustments will be made based on experience and qualifications