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About the Role

Ensures the integrity and accuracy of claims processes and protocols by collecting data for audits and investigations, identifying opportunities to target fraud, waste, and abuse, and analyzing data to assess claim validity. Provides recommendations for claim resolution and closure, documenting findings and preparing comprehensive reports.

Responsibilities

• Conducts routine and impartial audits/investigations from start to closure into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed.
• Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
• Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Assists in providing training and support to other auditors/investigators, contributing to the continuous improvement of investigative processes.

Requirements

• Reviews documentation, interviews involved parties, and communicates with various stakeholders to gather relevant information for successful resolution and closure.
• Adheres to industry regulations and policies for managerial follow-up.
• Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.
• Plans and arranges own work; works with manager to prioritize projects.

Skills

• Analytical skills
• Attention to detail

Experience Level

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

Education Level

• Minimum Bachelor's Degree required