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About the Role

Ensures integrity and accuracy of claims processes. Collects data for claims audits and investigations, reviewing documentation, interviewing parties, and communicating with stakeholders for resolution. Identifies fraud, waste, abuse, or discrepancies in claims submissions. Adheres to industry regulations and policies. Analyzes data to assess claim validity and provides recommendations for resolution. Documents findings and prepares comprehensive reports for legal or investigative purposes.

Responsibilities

Conduct routine and impartial audits and investigations of customer claims, ensuring accurate assessments of validity.
Provide customer service by addressing inquiries and concerns, escalating audits/investigations as needed.
Compile detailed records of audit and investigation findings, ensuring accuracy and compliance.
Apply functional knowledge to create and implement strategies for fraud prevention.
Conduct interviews with witnesses, claimants, and stakeholders to gather claim information.
Communicate with internal teams to ensure proper processing of audits and investigations, adhering to legal and regulatory standards.
Communicate audit and investigation findings clearly to customers, claimants, and stakeholders, managing expectations and providing updates.
Assist in providing training and support to other auditors and investigators.

Requirements

Minimum Bachelor's Degree required
2 - 4 years of experience required

Skills

Analytical skills
Attention to detail
Fraud prevention strategy implementation
Clear and professional communication
Certified Fraud Examiner (preferred)

Experience Level

2 - 4 years of experience required
5 - 7 years preferred

Education Level

Minimum Bachelor's Degree required