1. Individual will be responsible for reviewing industry intelligence information and determining potential exposure for National General Insurance Company. Individual will use the NetMap For Claims data mining application in this process and communicate findings to other SIU staff.
2. Individual will be responsible for reviewing questionable claim payments that are identified by the check audit system and verifying their authenticity. The following guidelines will be adhered to:
• Individual must view the invoice, bill or payment support document before approving the audited payment.
• Processing errors should be corrected with manager supervision and reported in "Comment" field.
• Suspect items must be forwarded to SIU for review and investigation.
3. Individual will be responsible for identifying additional criteria that should be used to identify questionable payments as well as tracking the success of the current audit criteria's.
4. Individual will be responsible for utilizing Netmap to proactively review payments for potential issues.
5. Individual will be responsible for developing and completing specific tasks associated with internal investigation action plans.
List of required qualifications for this position:
Bachelor Degree or equivalent business experience (Internal audit/investigation, field investigation and/or claims handling experience)
• Understanding of claim handling procedures as well as a knowledge of the payment process for all systems.
• Basic understanding of the claims/SIU policies and procedures; and ability to quickly review payments to identify payments that do not have supporting documentation and require further review.
• Ability to work diligently while reviewing multiple payments on a daily basis
• Understanding of Indicators of Internal Fraud
• Ability to develop action plans for internal investigations
• Prefer successful completion of the following:
-Claims handling classes
-AEI Coursework (FCLS OR FCLA)
-Indicator of Claims fraud training class
-CFE designation (Certified Fraud Examiner
List of qualifications desired for this position:
Desired candidate will have both claims handling experience and investigative/ internal auditing experience.
Strong understanding of the documentation required for claim payments to be issued.
Completion of Indicators and Elements of Agent and Underwriting Fraud
Extensive experience working with both Claims system, Policy Management System, Microsoft Outlook, Excel and Word programs
CFE designation, Internal audit/investigation and/or field investigation experience is strongly preferred.
Experience in the usage of data analysis software and performing link analysis.
Note: Depending on qualifications this position may be filled at the grade level of K or J.