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Director Complex Claims

PRIMARY PURPOSE: To be responsible for managing SIU investigations of complex fraud schemes involving providers, vendors, attorneys and others;  to strategically partner with law enforcement, departments of insurance, legal counsel and internal stakeholders for fraud matters, to be responsible for the day to day activities, performance and development of the SIU complex fraud investigation team. 

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

Analyzes complex  fraud schemes involving providers, vendors, attorneys and others, to proactively  develop responsive strategies in liaison with senior leaders and other key stakeholders.

Proactively and strategically manages a complex fraud investigation case  inventory by assessing actions of the team and providing guidance as necessary.

Strategically partners with law enforcement, departments of insurance, legal counsel, and internal stakeholders for fraud related matters.

Mentors and provides guidance to the SIU complex fraud team, analyst and compliance teams. 

Initiates and directs SIU compliance activities including carrier audits, state fraud reporting and internal management reporting

Establishes policy and procedure to assure compliance to SIU best practices and state regulations to meet carrier and client service requirements and to benefit our corporate stakeholders.

Utilizes reporting to develop metrics and manage team performance

Meets with the team to roundtable issues within their caseloads.

Provides individual coaching and development and small group training as needed.

Meets with leadership to review issues, trends, and recommendations to further influence and create a culture of continual quality improvement.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

Performs other duties as assigned.Supports the organization's quality program(s).Travels as required.

SUPERVISORY RESPONSIBILITIES

Administers company personnel policies in all areas and follows company staffing standards and training recommendations.Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions.Provides support, guidance, leadership and motivation to promote maximum performance.

QUALIFICATION

Education & Licensing

Bachelor's degree from an accredited college or university preferred. Fraud Claims Law Associate (FCLA), Certified Insurance Fraud Investigator (CIFI), or Certified Fraud Examiner (CFE) strong preferred, or equivalent relevant certification.

Experience

Ten (10) years of related experience  in fraud  detection, investigation, management, and compliance to include three (3) to five (5) years of supervisory experience handling complex fraud investigations, or equivalent combination of education and experience required.

Skills & Knowledge

Strong knowledge of major case and/or fraud ring investigationsKnowledge of fraud detection & investigation techniques, software and databasesStrong knowledge of laws related to fraud, abuse, investigation, and state insurance reportingExpert witness, deposition, and trial testimony skillsLines of business expertiseLeadership/management/motivational skillsAnalytical and interpretive skillsStrong organizational skillsExcellent interpersonal skillsExcellent negotiation skillsExcellent oral and written communication skillsPC literate, including Microsoft Office productsAbility to work in a team environmentAbility to meet or exceed Service Expectations

WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.