Life Special Investigations Unit Investigator I – Mid-Level – Medicare Supplement Fraud Waste & Abuse
| Company | USAA |
|---|---|
| Location | Tampa, FL, USA, Colorado Springs, CO, USA, Plano, TX, USA, San Antonio, TX, USA, Phoenix, AZ, USA |
| Salary | $63590 – $121530 |
| Type | Full-Time |
| Degrees | Associate’s |
| Experience Level | Mid Level |
Requirements
- High School Diploma or General Equivalency Diploma required.
- 2 years of life insurance claims and/or investigation experience.
- Proficient knowledge of life insurance products, claims, and underwriting.
- Proficient knowledge and understanding of fraud investigations as well as application of state/federal laws and regulations.
- Ability to gather a broad range of evidence and draw conclusions based on the objective details.
- Strong oral and written communication skills.
- Demonstrated experience analyzing and interpreting data to identify trends and patterns.
Responsibilities
- Conducts moderately complex investigations for life, health, and annuity products for potential claims fraud.
- Gathers evidence through interviews, searches of investigative databases, internal resources, internet resources, medical records, law enforcement records, and/or public records to support conclusions while adjusting investigative strategies as necessary.
- Prepares detailed and comprehensive investigative reports to summarize and substantiate the results/outcome of the investigation.
- Applies proficient knowledge of state/federal laws and regulations and legal concepts, including contract and case law, to ensure investigations are conducted within regulatory requirements.
- Applies proficient product and system knowledge to ensure appropriate investigation and/or claim settlement.
- Proactively manages the life of an investigation and acts as the liaison between the member, legal counsel, law enforcement, and other related agencies, as appropriate.
- Submits Department of Insurance fraud reports in compliance with established regulatory guidelines and time frames.
- Uses evidence of investigation and supporting documentation to make claim settlement determinations and recommendation for claim payments.
- Represents USAA at mediations and/or trial as required.
- Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.
Preferred Qualifications
- US military experience through military service or a military spouse/domestic partner
- 5 or more years healthcare/insurance claim investigations experience or law enforcement investigations experience.
- 2 or more years Medicare or Medicare Supplement claims experience.
- FE, AHFI, CHC, or other relevant industry designations.
- Associate degree or higher in criminal justice or a related field.
- Knowledge of claim billing codes, medical terminology, anatomy, and health care delivery systems.