SIU Investigator Resume
Summary : Dedicated and motivated SIU Investigator professional with more than 7 years of experience investigating and resolving insurance claims. Demonstrated expertise in coverage analysis, accurate evaluation of damages, and successful negotiation of bodily injury claims with first and third-party claimants and attorneys. Handled all lines of business, including personal auto, commercial auto, workers' compensation, and commercial general liability.
Skills : Surveillance, Interviewing, Investigating.
Description :
- Documented initial and final case reports and used them in court trials.
- Assisted in the up-gradation of the SIU systems through valuable inputs.
- Verified the validity of claims and understood the types of coverages provided.
- Reviewed claim forms and analyzed the submitted documents.
- Conducted interviews of claimants and witnesses and examined properties and vehicles.
- Performed background checks of claimants and identified connections of witnesses with the claimants.
- Visited the scene of accidents, and fire to analyze the damage caused.
Experience
7-10 Years
Level
Management
Education
Bachelor's In Criminal Justice
SIU Investigator Resume
Summary : A dedicated and highly accomplished claim/compliance manager with comprehensive experience in claims handling, vendor management, regulatory compliance, fraud investigation, claims personnel hiring and development, and case management. Customized a wide variety of workshops, courses, and programs to optimize the performance of employees, expanding scope, and volume and ensuring accurate outcomes.
Skills : Decision Point, Microsoft Word, Certified Fraud Examiner, Professional Certified Investigator.
Description :
- Received cases and verified claim information based upon referrals from the claim department.
- Conducted EUOs and took notarized statements from claimants to verify accident details and medical treatment received.
- Conducted fieldwork which included medical clinic inspections, patient file reviews, and surveillance.
- Lesioned with other claim offices by providing or obtaining information on medical providers to assist them in defending cases brought against the company.
- Conducted major case investigations which may lead to affirmative litigation and possible restitution.
- Assisted claim counsel and panel counsel with obtaining affidavits from medical providers which may lead to dismissal of suits against the company.
- Monitored various sites for updated information on disciplined doctors, lawyers, and medical clinics.
Experience
7-10 Years
Level
Management
Education
Bachelor's In Criminal Justice
SIU Investigator Resume
Summary : As an SIU Investigator, conducted thorough analysis of a claim file, application, or insurance transaction, that included consideration of factors indicating insurance fraud.
Skills : Surveillance, Interviewing, Investigating.
Description :
- Maintained order, discipline, and security of inmates in County facilities; supervised the security and conduct of inmates in cells, during transports, during group meetings, meals, bathing, recreation, visitations, court proceedings, and on work assignments.
- Performed internal security checks to include a visual inspection of the wellbeing of inmates; performed perimeter check/security checks throughout shift.
- Answers inmate questions, conducts investigations, interviews witnesses, victims, and complainants, and seizes evidence.
- Made arrests, wrote inmate misconduct reports, special reports, and crime reports, prepared cases, testified in judicial proceedings or before a Hearings Officer; maintained records and wrote reports.
- Processes inmates admitted and discharged for transfer from facilities; activities include booking and release, fingerprinting, photographing, custody level assessment, medical screening, clothed and unclothed body searches, and issuing of clothing and supplies to new inmates.
- Receives and maintains the personal property of inmates; returns personal property to inmates on discharge.
Inspects living quarters of inmates for contraband; checks on sanitary conditions and orderliness of living quarters.
- Follows orders/instructions from doctors or nurses in the care of ill inmates.
Experience
7-10 Years
Level
Management
Education
Bachelor's In Criminal Justice
SIU Investigator Resume
Summary : As an SIU Investigator, conducted field investigations in a dynamic fast-paced environment. Investigated may contain elements of fraud or claims otherwise deemed suspicious in nature within all lines of business, including Auto, Property, General Liability, and Workers' Compensation. Provided investigative expertise to detect fraud, limit exposure, and protect company assets.
Skills : Microsoft Access, Excel, Business Objects, Claims Handling, Medicare/Medicaid Billing knowledge, CPT Codes, Medicare Policy, data analysis.
Description :
- Referred suspicious PIP to the National Insurance Crime Bureau and Florida Department Services - Division of Insurance Fraud.
- Documented all findings and prepared investigation reports.
- Established and maintained close working relationships with Traveler's Claim Services, marketing, underwriting, claimants, policyholders, and agents, as well as financial institutions, government/regulatory agencies, and potential customers.
- Represented the Special Investigations Unit as a technical resource.
- Trained claims examiners, claims managers, and department managers on how to detect and handle external, internal, civil, and criminal fraud.
- Generated significant cost savings.
- Promoted from Senior Workers' Compensational Litigation Specialist.
Experience
10+ Years
Level
Senior
Education
Bachelor's In Criminal Justice
SIU Investigator Resume
Summary : To secure a SIU Investigator position where I am able to apply supervisory skills and experience all while building a lasting beneficial relationship with my employer. Analyzed, monitored, and conveyed highly technical information into actionable investigative strategies including the identification of complex case investigations.
Skills : Internal Controls, Audit, Accounting, Customer Service, Project Management, Presentations.
Description :
- Worked with local law enforcement and legal authorities pursuing criminal investigations.
- Participated in mediation for liability claims.
- Conducted interviews, and EUOs, completed background searches and neighborhood canvasses, and collected evidence.
- Completed report writing while maintaining and documenting files.
- Initiated hundreds of investigations by analyzing data to identify cases of government fraud, waste and abuse by providers and members resulting in the recovery of approximately $2.5 million.
- Investigated several employee misconduct cases that led to process improvements and the closing of security gaps.
- Participated in the selection of vendors who provided products and services used by the Special Investigation Unit as well as other Fidelis departments.
Experience
10+ Years
Level
Senior
Education
Business Administration
SIU Investigator Resume
Objective : Obtain an SIU Investigator position in the healthcare or insurance industry where I can maximize my knowledge of handling insurance claims and offer my experience of conducting successful investigations to ensure program integrity while protecting assets and resources.
Skills : Investigative and analytical skills.
Description :
- Developed and maintained policies and procedures related to fraud, waste, and abuse per state and federal regulations.
- Developed tailored claims edits and filters to prevent payment on fraudulent or abusive claims.
- Collaborated with other departments to ensure Compliance with state and federal Program Integrity requirements.
- Performed data analysis on provider billing patterns and license details to determine if the investigation was warranted.
- Protected the Health Plan from civil and monetary penalties related to fraud, waste, and abuse.
- Presented investigation findings to appropriate management, government, and regulatory agencies as required.
- Trained all new employees on the Corporate Compliance Program and HIPAA.
Experience
2-5 Years
Level
Executive
Education
Business Administration
SIU Investigator Resume
Summary : As an SIU Investigator, supported the SIU operation by investigating suspicious claims, conducting background and investigative research, compiling reports, and communicating with internal and external customers. Participated in developing and delivering training on anti-fraud and other property claim topics.
Skills : Investigations, Conducting interviews, and interrogations.
Description :
- Investigated Auto, Homeowners, and workers Comp Insurance Claims in Arkansas - Collected, analyzed, and evaluated the information gathered to provide the claims representative with information to make a decision on the claim.
- Set up or conducted EUOs.
- Obtained recorded statements from key persons related to the loss.
- Conducted records & database records searches on insured's or claimants' utilizing ISO records and public records searches.
- Obtained financial, and medical records and database searches.
- Consulted with attorneys, engineers, reconstruction engineers, biomechanical engineers, and law enforcement agencies to obtain supporting information.
- Provided training to agents & claims personnel on fraud detection & fraud awareness.
Experience
7-10 Years
Level
Management
Education
Business Administration
SIU Investigator Resume
Objective : As an SIU Investigator, responsible for Assisting Claims Advocates in proper investigations as they pertain to suspicious indicators, Serving as a liaison between NICB & local and federal law enforcement agencies, and Establishing and maintaining a professional working relationship with Lemonade Integral Staff.
Skills : Insurance policies, Regulations.
Description :
- Conducted accident scene investigations of contracted clients.
- Obtained written and recorded statements of witnesses and injured parties.
- Testified in court proceedings to information received during the investigation.
- Interviewed and corresponded with witnesses and claimants.
- Investigated and estimated damage to property.
- Analyzed information collected by investigation and reported findings and recommendations.
- Trained new employees.
Experience
2-5 Years
Level
Junior
Education
Business Administration
SIU Investigator Resume
Summary : Dynamic, effective SIU Investigator, conducted investigations of varying complexity related to suspicious/fraudulent P and C claims. Documented, and pursued information in accordance with Orion180 core best practices, and will refer all matters of insurance fraud to the appropriate regulatory agencies.
Skills : Microsoft Office, Office Equipment And Procedures.
Description :
- Provided fraud training and suspicious claim investigations as a part of company anti-fraud efforts.
- Conducted interviews and recorded statements with insureds, and witnesses.
- Prepared and presented case evidence to law enforcement where appropriate.
- Interacted with management at all levels.
- Coordinated investigative efforts with other SIU units.
- Sought new sources for training in fraud trends for claims personnel.
- Completed field investigations in Texas, Oklahoma, and Mississippi involving claim files.
Experience
10+ Years
Level
Senior
Education
Business Administration
SIU Investigator Resume
Summary : As an SIU Investigator identified and interviewed potential witnesses who may provide information on the accuracy of the claim or application.
Skills : Investigations, Conducting interviews, and interrogations.
Description :
- Preserved documentation and/or other evidence obtained during an investigation.
- Wrote a concise and complete summary of the entire investigation meeting the required criteria.
- Coordinated and conducted EUO examinations as warranted to aid in the final outcome of a claim investigation.
- Investigated each credible referral of suspected insurance fraud that it receives from the integral anti-fraud personnel, including automated or system-generated referrals.
- Ensured effective implementation of fraud detection and/or deterrent protocols.
- Reported all suspected fraudulent insurance transactions to the appropriate parties within the required timeframes.
- Participated in the support, and service resources, to meet account performance objectives and the company’s expectations.
Experience
7-10 Years
Level
Management
Education
Business Administration
