Major Case Investigator Central Insurance Company - 3.5 Irving, TX Job Details Full-time 1 hour ago Benefits Health insurance Qualifications Claim investigation National Correct Coding Initiative (NCCI) guidelines Insurance investigation report preparation Healthcare billing investigations

Full Job Description Location:

Van Wert, OH; Dublin, OH; Waltham, MA; Alpharetta, GA;

Irving, TX Work Model:

Hybrid or Remote based on location Position type: Full time - salary We're a team of employees passionate about delivering best-in-class customer service and driving innovation in claims management. Integrity, relationships, and excellence are at the heart of everything we do. Our employees fully utilize their talents and bring their best selves to work. We believe who you are is just as important as what you do! At Central, protecting our policyholders and maintaining the integrity of every claim are essential to delivering on our promise of excellence. Our Anti-Fraud and Recovery team combines investigative expertise, advanced analytics, and strong industry partnerships to identify complex fraud, protect company resources, and support fair, accurate claim outcomes. As a Major Case Investigator, you will take the lead on sophisticated investigations that make a meaningful difference for Central, our customers, and the insurance industry. Key Responsibilities of the Role Under limited supervision, conducts extensive and detailed investigations on high-complexity suspicious losses or organized schemes involving staged accident rings, medical provider treatment and billing rings or investigations on general contractors to include public adjusters, roofing and mitigation companies. Partners with various SIU and line of business claims personnel to determine merits of initiating organized scheme investigations. Assists in developing training and provide fraud awareness training and technical advice to internal stakeholders. Develops and executes appropriate investigation strategy for assigned cases more complex in nature, specifically organized/ring related. Gathers and evaluates data from multiple internal and external sources to identify and investigate potential fraudulent insurance acts involving Central policies. Leads in-depth interviews of insureds, witnesses, medical professionals, claimants or any other party associated with the claim. Completes detailed and extensive investigations in adherence with SIU procedures and best practices. Assists in developing training and provide fraud awareness training and technical advice to internal stakeholders. Establishes relationships and present cases to the Department of Insurance, NICB, state, local, and federal law enforcement, medical boards, Department of Professional Licensing, and any other department deemed necessary. Seeks other potential sources of prosecutorial administrative actions such as the Better Business Bureau, Federal Trade Commission, State Attorney General, and any other entities deemed necessary. Required Qualifications Bachelor's degree and 4 years of investigative/Law Enforcement or insurance investigation experience Or 6 years of investigative/Law Enforcement or insurance investigation experience Ability to travel as assigned Preferred Qualifications Subject Matter Expert within medical fraud area Certified Fraud Examiner-CFE or Health Care Fraud Investigator Fraud Claims Law Specialist designation (FCLS) Certified Insurance Fraud Investigator designation (CIFI) Knowledge, Skills, and Abilities Advanced practical knowledge of conducting clinic inspections and field investigations. Maintains extensive network with law enforcement agencies and works in collaboration in the investigation of suspicious losses. Ability to analyze and interpret complex and voluminous evidence and convey highly technical information effectively to others. Strong knowledge of CPT codes, fraudulent billing practices such as up coding, unbundling and inflated practices is a must. Must be able to prepare and submit detailed investigative reports as necessary and make investigative recommendations. Demonstrated ability to conduct extensive and complex suspicious loss investigations and/or lead organized scheme investigations. Ability to understand Central Insurance's policies and processes Total Rewards Central establishes base pay based on several factors including labor market data and an evaluation of candidate qualifications relative to role requirements. Base pay is one component of a comprehensive total rewards package designed to support employees' financial, health, career, and retirement objectives. Central provides extensive health and wellness benefits to promote flexibility, work-life balance, and long-term financial security. For more information, see Central Insurance Benefits Work Authorization Central will only employ those who are legally authorized to work in the United States. This is not a position for which sponsorship will be provided. Individuals with temporary visas such as E, F-1(including those with OPT or CPT), H-1, H-2, L-1, B, J or TN, or who need sponsorship for work authorization now or in the future, are not eligible for hire. Equal Opportunity Employer It is the policy of Central that all recruiting, hiring, training, compensation, overtime, job classification and assignment, facilities, promotions, transfers, employee treatment and all other terms and conditions of employment shall be maintained in a manner which will not discriminate against any person because of race, color, age, sex, national origin, ancestry, religion, marital status, military status, or disability. The applicant should respond to questions on this application in a way that will not divulge such information. #LI-AS1 #LI-Hybrid #LI-Remote