The Hartford SIU – Medical Fraud and Major Case Consultant in RANCHO CORDOVA, California

Title: SIU – Medical Fraud and Major Case Consultant

Location: United States-California-Rancho Cordova

Other Locations: United States-California-San Francisco

Job Number: 1701046

Reporting to the SIU Director of SIU Operations and Major Case Investigative Programs, the SIU Medical Fraud & Major Case Consultant position will be responsible for developing and executing effective investigative plans into complex, organized fraud exposures. The position will also work in conjunction with the SIU Field Organization, SIU Forensic Data Analytics Operation, Corporate Legal, & other Business Groups, to support the Workers Compensation, Auto, Property, General Liability, Underwriting & Group Benefits business areas.

The SIU Medical Fraud & Major Case Consultant must exhibit higher levels of effective Leadership, Teamwork, Business Analysis, Problem Solving & Resolution skills. This position also requires a high level of knowledge in forensic data analysis approaches & techniques. In addition, this role requires the abilities to be highly flexible, committed & engaged, while having exceptional time management skills and proactive execution abilities to balance multiple priorities.

The position will include some travel to The Hartford’s business & customer locations on a national level to support relationship building, organization collaboration, identifying improvement and innovation opportunities, and to complete key investigations including face to face interaction with parties to a loss, including insured’s, claimants, witnesses, experts and other professionals.

In addition to completing investigations, this position will be responsible for the continued identification of workflow inefficiencies, current & future vulnerabilities to organized fraud schemes, and must function with a continuous improvement mindset. This consultant must have a strong working knowledge of:

  • Medical bill coding
  • Applicable healthcare regulation
  • Investigative techniques focused on organized fraud issues

Additional responsibilities include:

  • Relationship building, creativity, leadership and a desire to move forward into the future of major case investigation with a focus on data driven investigations that affect the enterprise.
  • Ensure collaboration & maintain relationships with all Business Partners while marketing SIU services and educate center personnel as to value proposition of SIU.
  • Interface with SIU Community and Law Enforcement: Participate in industry meetings and is aware of developments and emerging trends related to insurance fraud schemes nationally. The position must be able to liaison with industry peers and leaders and where necessary, interface with law enforcement per prescribed jurisdictional requirements and must be able to recognize opportunities to leverage information to appropriate personnel within The Hartford.
  • Understand the legal & regulatory environments on a national level.
  • Project Work: Lead or assist on SIU or internal project teams as assigned. Effective partnership and collaboration skills are required in working with diversified groups. Identify issues and contribute new ideas and innovative thinking in surfacing solutions. Act as an overall champion for SIU Services in provide anti-fraud information on a national level.
  • Be highly knowledgeable in areas of: appropriate investigative techniques & strategies pertaining to large scale / organized fraud schemes, laws pertaining to insurance claims, mandated reporting, good-faith investigative techniques and understanding of emerging issues impacting Property & Casualty and Group Benefits claims.
  • Fully comply with statutory, regulatory and ethics requirements.
  • Effectively communicate and teach a thorough understanding of business vision, strategies and plans for achieving business goals.
  • Effectively train, coach and develop staff to enable optimal job performance and the achievement of individual and professional goals.
  • Conduct training on fraud issue on an as needed basis.


Qualifications:

  • SIU / Insurance Fraud - Medical & Major Case investigative background with proven track record of success working Large Scale Organized Fraud Investigations; 3 years of minimal experience preferred.
  • Highly knowledgeable of CPT Coding, ICD9/ICD10 Coding, Medical billing & treatment fraud, waste, & abuse in areas to include but not limited to: Chiropractic, DME, Electro Diagnostic Testing, Hospital & ASC Operations, and billing techniques and abuse areas.
  • Experience with Affirmative Litigation strategies and Anti-Fraud Deterrence methods.
  • Familiar with WC Lien environment in States / Jurisdictions where applicable.
  • Understanding of the legal & regulatory environments on a national basis.
  • Effectively communicate and present investigative findings to all levels of the organization both in writing and through virtual and in person presentations.
  • Abilities to create / foster teamwork and relationship building.
  • Understanding of financial & business intelligence for analysis and action planning.
  • Demonstrated leadership Abilities & Aptitude.
  • Consistent high level of performance and achievement over career span.
  • Engagement in or having successfully completed Leadership Development Programs a plus.
  • Strong computer skills in all Microsoft Office products and the utilization of the internet; advanced Excel skills a plus.
  • Strong Project Management Skills
  • Experience in training, both formal & informal.
  • Strong customer service focus
  • Strong strategic thinking and planning abilities.
  • Strong abilities to create / foster teamwork and relationship building.
  • Ability to Travel nationally on a routine basis.
  • Minimum of Bachelor’s degree required
  • CPCU, AHFI, or other professional designations, or working toward such designations.

Competencies:

  • Demonstrated leadership skills in terms of teaching, guiding, and building consensus on a plan of action.
  • Strong communication skills, both verbal and written regardless of audience demographic.
  • Ability to partner with internal and external customers.
  • Advanced analytical skills in terms of functional, technical and financial information.
  • Strong court testimony skills
  • Inspires excellence
  • Delivers results
  • Trusted decision maker
  • Enterprise team player
  • Innovative or forward thinker
  • Talent champion

Behaviors at The Hartford

  • Deliver Outcomes – Demonstrate a bias for speed and execution that serves our shareholders and customers.
  • Operate as a Team Player – Work together to drive solutions for the good of The Hartford.
  • Build Strong Partnerships – Demonstrate integrity and build trust with others.
  • Strive for Excellence – Motivate yourself and others to achieve high standards and continuously improve.

The Hartford is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law.

The Hartford maintains a drug-free workplace and is committed to building inclusion and leveraging diversity.


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