SIU - Senior Investigator

ICW Group is a leading provider of insurance services, with over 50 years of experience and headquartered in San Diego. We are committed to delivering the best insurance experience possible.

PURPOSE OF THE JOB

The Senior Special Investigation Unit (SIU) Investigator works to detect, prevent, and investigate suspected fraudulent claims for all lines of insurance, with focus aligned to enterprise risk priorities. This position exists to protect company assets through examining potential fraudulent cases. The work is aligned to either Desk or Field investigative assignments.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Leads Complex and Major Case Investigations Conduct advanced, large-scale investigations involving organized fraud rings, provider fraud schemes (medical, legal, and ancillary services), referral/kickback schemes. Identify patterns of coordinated activity across multiple claims to detect systemic and enterprise-level fraud risks. Independently manage complex, multi-jurisdictional cases from inception to resolution. Interview claimants, witnesses, employers, medical providers, and legal representatives, utilizing advanced interviewing and interrogation techniques. Develop and secure recorded statements, affidavits, and evidence to support investigative findings. Perform on-site investigations, clinic inspections, and surveillance coordination as appropriate. Data Analysis & Intelligence Development Interpret and synthesize large volumes of data from multiple sources, including claims systems, billing records, social media, and third-party databases. Identify anomalies, trends, and networks/relationships indicative of fraud through link analysis and data correlation. Develop actionable intelligence packages to support internal stakeholders and external enforcement actions. Provider & Organized Fraud Focus Identify and investigate fraud involving service providers, legal entities, and billing schemes, including upcoding, billing irregularities, and treatment patterns inconsistent with injuries. Coordinate with internal and external experts to evaluate medical necessity, treatment patterns, and provider networks. Fraud Detection & Case Development Evaluate referrals for fraud indicators and determine appropriate investigative strategies. Build comprehensive case files supported by well-documented evidence, timelines, and investigative summaries. Ensure all findings meet standards required for regulatory reporting, civil litigation, and criminal prosecution. Collaborates with Legal & Regulatory Entities Partner closely with law enforcement, district attorneys, regulatory agencies, and legal counsel to advance cases. Present investigative findings in a professional manner for case review, prosecution, or civil recovery actions. Maintain detailed knowledge of relevant laws, regulations, and evidentiary standards. Case Management & Reporting Produce clear, concise, and defensible investigative reports covering all aspects of the case lifecycle. Maintain accurate documentation in case management systems and ensure timely progression of cases.

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities.

EDUCATION AND EXPERIENCE

Bachelor’s degree with a major in Criminal Justice, Business, Accounting, Information Systems, or closely related (or an equivalent combination of education/experience). Minimum of 5 years’ related work experience required. The Senior SIU Field Investigator requires experience specifically in investigations and/or law enforcement.

CERTIFICATES, LICENSES, REGISTRATIONS

Private Investigator's License or fraud related certificates (CFE, CIFI) preferred. Requires valid Driver’s license.

KNOWLEDGE AND SKILLS

Good computer skills in Microsoft Office/Outlook and expertise using investigative case management software/tools (such as Polonious or similar) Experience with case management systems and investigative tools Fundamental knowledge of claims management processes and claims handling Knowledge of Unfair Claims Practices Act, Legislative, and Insurance Department regulatory requirements Familiarity with civil/criminal investigation procedures and the legal system Demonstrated experience with managing relationships to complete thorough investigations High level of critical thinking, attention to detail, and independent judgment Excellent written/verbal and presentation skills Experience with advanced investigative and interviewing skills Ability to analyze and interpret large, complex data sets Strong knowledge of fraud schemes, claims handling, legal procedures, and medical / services billing Ability to present information within a courtroom setting

PHYSICAL REQUIREMENTS

Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear.

WORK ENVIRONMENT

This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment. Salary The current range for this position is $78,678.61 - $132,686.15. This range is exclusive of fringe benefits and potential bonuses. If hired at ICW Group, your final base salary compensation will be determined by factors unique to each candidate, including experience, education and the location of the role and considers employees performing substantially similar work.

WHY JOIN ICW GROUP?

Challenging work and the ability to make a difference You will have a voice and feel a sense of belonging We offer a competitive benefits package, with generous medical, dental, and vision plans as well as 401K retirement plans and company match Bonus potential for all positions Paid Time Off Paid holidays throughout the calendar year Want to continue learning? We’ll support you 100% Equal Opportunity Employer Statement ICW Group is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer. ICW Group will not discriminate against an applicant or employee on the basis of race, color, religion, national origin, ancestry, sex/gender, age, physical or mental disability, military or veteran status, genetic information, sexual orientation, gender identity, gender expression, marital status, or any other characteristic protected by applicable federal, state or local law. #J-18808-Ljbffr ICW Group