Claims Representative, SIU

Job description

We are seeking a highly skilled and motivated candidate with specialized experience in NJ provider/PIP initiatives to join our team in order to assist with Major Case Investigation . The ideal candidate will have a strong background in identifying, investigating, and resolving complex cases of insurance fraud within the Personal Injury Protection (PIP) and healthcare provider space. Proficiency in investigative techniques, industry regulations, and PIP claim regulations is essential. RESPONSIBILITIES: - Lead and conduct comprehensive investigations into major fraud cases, including healthcare fraud, staged accidents, exaggerated injuries, and fraudulent billing practices related to PIP claims. - Analyze and review claims data to identify red flags, trends, and patterns indicative of fraudulent activity, particularly focusing on NJ provider claims. - Collaborate with internal teams, external stakeholders, and law enforcement agencies to gather evidence and build cases. - Interview witnesses, claimants, and providers as part of the investigative process, documenting findings thoroughly. - Provide detailed reports and recommendations on cases for potential legal action or denial of cl...