Senior SIU Major Case (Medical Provider Investigations)

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families. Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful. We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. The Opportunity As a dedicated Senior SIU Major Case (Medical Provider Investigations) , within defined guidelines and framework, protects USAA and our members from potential fraudulent claims by investigating complex fraud investigations with significant financial impact to USAA which may involve Legal Counsel, government agencies and outside consultants in compliance with state laws and regulations for an assigned operational specialty team. This role is remote eligible in the continental U.S. with occasional business travel. What you'll do: Leads the execution of fraud prevention strategies and investigative operations. Leads high exposure, high profile and sensitive work assignments, and special investigations involving complex specialized fraud referrals, (examples: organized provider rings, staged accidents, large losses of significant exposure and broad scale PIP/Casualty Schemes) across multiple entities or functions. Applies advanced knowledge of P&C insurance industry products, services, and processes in investigating claims. This includes P&C insurance policy contracts and coverages and claims handling process and procedures. Applies advanced knowledge of state laws and regulations pertaining to insurance fraud in investigating claims. Processes large quantities of unstructured detailed information with high levels of accuracy by collecting evidence of potential fraud through field or remote interviews and thorough searches of investigative databases, internal resources, Internet resources, public records, and forensic tools. Makes appropriate and prompt decisions to identify potential complex fraud within defined guidelines. Prepares and presents detailed and comprehensive verbal and written investigative reports summarizing the results and outcome of the investigation. Serves as subject matter expert for team members including providing expert guidance and training for fraud investigations. Develops and maintains external relationships with industry, law enforcement and other contacts involved in fraud investigation, detection, and prevention. Develops proactive actions and conveys compelling arguments to influence disposition of arbitrated and litigated cases effectively and efficiently. Handles CAT duty responsibilities as business requires. Ensure risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures. What you have: High School Diploma or General Equivalency Diploma 3 years of P&C SIU/Fraud Major Case investigation experience; or 4 years of medical provider claims experience (third-party BI experience does not qualify) Expert knowledge and understanding of fraud investigations as well as application of case law and state laws and regulations. Must be a results-oriented, skilled investigator with experience taking complex statements from multiple parties to an event. Ability to gather broad range of evidence and draw conclusions based on objective details related to the applicability of fraud. Demonstrated ability to organize and prioritize workload, performing multiple tasks and devising solutions to problems. Experience using computers and various software packages to enter and extract data for analysis from relevant data sources and systems. Knowledge of city, state and local regulations, legal concepts, understanding of contracts, case law, medical treatment, and medical terminology. Experience in concurrent handling of specialty/complex/litigated claims/cases as well as mediation/arbitration/trial preparation and participation. What sets you apart: Experience developing cases for affirmative litigation P&C Major Case Medical provider investigation experience US military experience gained through military service or gained as a military spouse / domestic partner. Compensation range: The salary range for this position is: $93,770 - $179,240 . USAA does not provide visa sponsorship for this role. Please do not apply for this role if at any time (now or in the future) you will need immigration support (i.e., H-1B, TN, STEM OPT Training Plans, etc.). Compensation: USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors. The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job. Benefits: At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals. For more details on our outstanding benefits, visit our benefits page on USAAjobs.com Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting. USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.