[Hiring] SIU Medical Provider Fraud Investigator @Allstate

Role Description

This role is responsible for identifying suspicious medical provider businesses, attorneys, and law firms that may be connected for the purpose of generating fraudulent payments. The individual will conduct thorough investigations by identifying injured parties, billing trends, treatment sequences, attorney relationships, and claim reporting patterns. This role typically handles bodily injury claim files, including both non-litigation and litigation matters.

We are seeking an experienced SIU Medical Provider Fraud Investigator, preferably located within the Central Time Zone, who holds an active Texas All-Lines Adjuster License or a reciprocal state license. The ideal candidate brings a strong investigative mindset with the ability to:

• Identify suspicious patterns
• Conduct complex medical provider fraud investigations
• Thoroughly document findings

Success in this role requires:

• Exceptional organizational skills
• Attention to detail
• Analytical thinking
• Ability to manage multiple investigations effectively
• Strong written and verbal communication skills
• Ability to collaborate with internal partners
• Present investigative findings in a clear, concise, and professional manner

Qualifications

• Active Texas All-Lines Adjuster License or a reciprocal state license
• Experience in fraud investigations

Requirements

• Enters SIU claim data information into multiple SIU systems
• Reviews investigations with fraud outcomes to validate whether denial is appropriate
• Updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement
• Conducts complex online data application searches, research, and evaluation
• Conducts complex site inspections, including body shops, medical clinics, loss locations, etc.
• Conducts thorough investigations of complex cases that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed
• Validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
• Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process
• Utilizes analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages
• Researches and responds to complex customer communications, concerns, conflicts or issues

Benefits

• Base compensation offered for this role is:
• SIU Cons I: $60,000.00 - $87,400.00/salary
• SIU Cons II: $62,100.00 - $92,700.00/salary
• Compensation is based on experience and qualifications.
• Total compensation for this role may include additional components, such as incentive pay (for example, commission or bonus), if applicable.

Company Description

Joining our team isn’t just a job — it’s an opportunity. One that takes your skills and pushes them to the next level. One that encourages you to challenge the status quo. One where you can shape the future of protection while supporting causes that mean the most to you. Joining our team means being part of something bigger – a winning team making a meaningful impact.