Claims SIU Investigator II (Remote)

The world isn’t standing still, and neither is allstateWe’re moving quickly, looking across our businesses and brands and taking bold steps to better serve customers’ evolving needsThat’s why now is an exciting time to join our teamYou’ll have opportunities to take risks, challenge the status quo and shape the future for the greater good.

You’ll do all this in an environment of excellence and the highest ethical standards – a place where values such as integrity, inclusive diversity and accountability are paramountWe empower every employee to lead, drive change and give back where they work and liveOur people are our greatest strength, and we work as one team in service of our customers and communities.

Everything we do at allstate is driven by a shared purpose: to protect people from life’s uncertainties so they can realize their hopes and dreamsFor more than 89 years we’ve thrived by staying a step ahead of whatever’s coming next – to give customers peace of mind no matter what changes they faceWe acted with conviction to advocate for seat belts, air bags and graduated driving lawsWe help give survivors of domestic violence a voice through financial empowermentWe’ve been an industry leader in pricing sophistication, telematics, digital photo claims and, more recently, device and identity protectionWe are the good handsWe don’t follow the trendsWe set them.

We are looking for experience with medical claims; with hopefully experience in first party medical and/or no fault/pip

Knowledge/skills/abilities/experience

Bachelors degree in related field preferred or equivalent experience
 ability to interact effectively, and coach others on interacting effectively, with internal or external customers and act with empathy
 applies broad knowledge of insurance policy, coverage, and regulation
 applies broad knowledge of claim processes, policies, procedures, claim systems, coverage, liability, damage estimating, and/or settlement, and adherence to applicable legal compliance standards
 applies broad industry knowledge to discipline practices, including best practices, to support the business unit
 applies broad knowledge of analytical procedures to reconcile, manipulate, and recognize patterns of data
 applies broad knowledge of problem solving and preparation of reports for analysis
 applies broad ability to leverage learned technical skills in support of team objectives
 applies broad negotiation and/or arbitration skills
 applies broad conflict management and problem resolution skills in managing internal and external customer relationships
 applies broad problem solving skills to continuously improve business outcomes
 applies broad knowledge of training facilitation and coaching skills
 ability to investigate, evaluate, negotiate and settle complex claims
 provides broad individual decision making within authority limits
 has and maintains all appropriate licenses and registrations for the role per state requirements

Job family summary

The adjusting function is responsible for verifying policy coverage and limitsThe adjusting function investigates and evaluates damage and/or liability; estimates damages, losses, or total indemnity; sets and maintains reserves; and/or negotiates and settles claimsSpecial investigative unit (siu) work is performed by a specialized unit that proactively utilizes analytical tools to handle the most complex or specialized claims possibly in litigation and works with specialized counsel and law enforcement to detect, investigate, prosecute and deter fraud.

Job summary

Under limited supervision, this job is responsible for investigating and analyzing complex, multi-discipline coverage and claims that have been referred to the special investigation unit (siu) for potential fraudThis role typically handles a combination of complex attorney represented and unrepresented claims and moderate to complex losses, in which suspicious activity has been identifiedThe individual performs a thorough investigation including; (1) conducting background searches, scene investigations, and clinic inspections; (2) taking recorded statements; (3) reviewing and analyzing medical notes, bills, and property damage; and (4) conducting witness interviews and social media searchesThe individual conducts surveillance on property and/or creates scene reconstructions on some investigations and reviews whether fraud can be substantiated and supports a lawsuitThe individual provides work guidance and direction to less senior employees and provides mentoring and coaching to the teamThe individual also delivers compassionate service that is fast, fair, and easy, to ensure customer retentionThe individual works independently, prioritizing the individual`s own responsibilities, and managing the individual`s own workloadThe individual also consistently meets band level behaviors, production, quality, and/or customer service goals.

Key responsibilities

Customer service
 makes and maintains a connection with the customer by understanding and meeting their needs; serves the customer with empathy; and follows up to ensure that customer needs have been met
 researches and responds to complex customer communications, concerns, conflicts or issues
 reviews customer satisfaction results; participates in determining necessary personal and business unit action plans
File documentation and reporting
 summarizes documents and enters into claim system notes
 documents a claim file with notes, evaluations and decision making process
Siu (post-referral)
 verifies loss facts and coverage
 utilizes analytic tools or siu field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages
 attends industry, law enforcement and nicb meetings to obtain information on latest fraud schemes
 conducts thorough investigations of complex, attorney represented or unrepresented multi-discipline claims that are potentially fraudulent to determine if payment is warranted, including scene investigations and surveillance as needed
 validates that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
 has frequent customer interaction of a complex nature, including taking statements, responding to document requests and handling complaints
 conducts complex online data application searches, research, and evaluation
 conducts complex site inspections, including body shops, medical clinics, loss locations etc.
 collaborates with retained and staff counsel to develop strategies for advancing the investigation
 reviews investigations with fraud outcomes to validate whether denial is appropriate
 works in conjunction with law enforcement, as needed, on complex matters to pursue criminal charges if warranted
 updates files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to mco for further handling and settlement
 enters siu claim data information into multiple siu systems
 notifies appropriate state agencies, industry databases, and underwriting regarding fraud outcomes
 makes claim decisions regarding complex investigations, and pursues restitution
 utilizes applications/tools to analyze claim information and other data to reveal hidden patterns of activity across multiple claims
 works with mco/csa to meet customer experience and goals
 must be knowledgeable about state laws and regulations
 controls expenses through vendor management

Key responsibilities...

Legal bill reviewer
 applies legal billing guidelines
 achieves acceptable legal bill review variance to re-reviews
 achieves acceptable turn-around time compared to the country-wide average
 utilizes reports and updates mco leadership of trends
 conducts liaison/training with law firms
Litigation
 manages singular claims in litigation
 chooses defense counsel
 establishes or reviews litigation plan and participates in developing litigation strategy
Other projects and responsibilities
 may participate in one or more complex special assignments
 may serve as a committee team lead for medium-sized projects or as a committee team member on large projects involving complex case work
 manages vendor relationship and oversees vendor performance
 may serve as mco liaison
 facilitates training on fraud awareness for mcos and industry personnel
 collaborates with multiple aors
 attends training as required by state law or internal compliance, to further investigation skills

The candidate(s) offered this position will be required to submit to a background investigation, which includes a drug screen.

Good workGood lifeGood hands®.

As a fortune 100 company and industry leader, we provide a competitive salary – but that’s just the beginningOur total rewards package also offers benefits like tuition assistance, medical and dental insurance, as well as a robust pension and 401(k)Plus, you’ll have access to a wide variety of programs to help you balance your work and personal life - including a generous paid time off policyFor a full description of allstate’s benefits, visit allstate.jobs/benefits/

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Allstate generally does not sponsor individuals for employment-based visas for this position.

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