SIU Medical Specialist
Job Description
About the Role
Title: SIU Medical Specialist
Location: Worcester United States
SIU Medical Specialist
Howell, MI, USA Itasca, IL, USA Richmond, VA, USA Worcester, MA, USA Virtual Req #18199
Friday, August 30, 2024
For more than 170 years, The Hanover has been committed to delivering on our promises and being there when it matters the most. We live our values every day, demonstrating we CARE through our values, ESG initiatives and IDE journey.
Our special investigation unit is currently seeking a Medical Specialist to join our growing team. This position can by fully remote or hybrid in the following locations: Itasca, IL, Worcester, Ma, Howell, MI, Richmond, VA. This is a Full Time/Exempt role.
POSITION OVERVIEW:
The medical specialist is responsible for investigating, analyzing and supervising medical investigations to ensure all investigations comply with established policies, practices and procedures.
IN THIS ROLE, YOU WILL:
Supervise, coordinate and monitor activities of medical fraud investigations in order to obtain and ensure an accurate, quality product while maintaining high production and performance standards.
Evaluate and give guidance to investigators on an ongoing basis.
Coordinate and act as a liaison with other departments in which SIU interacts.
Recommend procedural changes, plan, organize and implement the changes under SIU leadership guidance.
Ensure proper reporting to appropriate state and fraud prevention agencies in accordance with company policy and regulatory requirements.
Research and analysis of complex medical investigations involving claims for all lines of business.
Provide continuing education on SIU initiatives to other departments.
Position to target assignments generated from: MedSentry, ABI, WC and CGL
Additional oversight on NICB alerts, ForeWarns, AMD’s, Strategic Alerts
Target states with low penetration rates to drive diversificationâCA, MA, NY, NJ, PA, GA and IL
WHAT YOU NEED TO APPLY:
Bachelor’s degree. Advanced degree preferred (e.g., nurse, medical field expertise).
Background in the following: medical terminology, procedures, injuries and medical coding, SIU investigation and litigation.
Prior medical SIU background, CPC, AHFI accreditation is desired
Analyze claims generating from the casualty service segment specifically claims from the SIU models for PIP, ABI, CGL and WC LOB’s.
Provide facts/information/details to the claims handler to mitigate the claim using intel from SIU resources; MedSentry, IES, Model details, Accurint, ISO, NICB alerts, AMD alerts, SIU watchlist alerts, Fraud alerts, task force detail
Leverage/manage field staff for RS, scenes work up, witnesses canvassing, clinic visits etc.
Supervise, coordinate and monitor activities of medical fraud investigations conducted by field personnel and management of approved PI vendors. Research and analysis of complex medical investigations involving claims for all lines of business in the casualty and specialized response teams.
Evaluate and give guidance to desk/field investigators.
Coordinate and act as a liaison with local, state, and federal medical fraud task forces that includes Medicare/Medicaid groups (attends meetings that drive referrals for trends/schemes identified by these task forces).
Ensure proper reporting to appropriate state and fraud prevention agencies in accordance with company policy, business expectations and regulatory requirements.
Provide continuing education on SIU initiatives in the medical fraud space to other departments.
Dedicated to meeting the expectations and requirements of internal and external customers.
Knowledge of internal and external customer’s needs and good faith claim practices.
Easily adapts to new, different or changing situations, requirements or priorities.
Ability to work independently with low dependency needs.
Applies knowledge of company products and processes to understand key customer issues and needs.
Able to provide clear and concise direction.
Effective analytical person, who anticipates issues, seeks out and analyzes information collaboratively to propose solutions.
Takes ownership for a successful resolution.
Possesses a strong moral and work ethic, is trustworthy and able to maintain confidentiality.
Low level of harm-avoidance or fear of conflict.
Aggressive learner and initiative-taker, committed to self-development.
Persistent, persevering and results driven.
Ability to be flexible and able to adjust to a high case volume environment.
Skilled at logical and creative thinking and ability to test information.
Proficient in utilizing technological systems (e.g., MS Office, excel, word, Power BI, Power Apps).
Familiarity with investigative techniques, such as interviewing and evidence collection.
Polished, well-spoken, and a collaborative person with an elevated level of written and verbal communication skills.
Strong mentoring skills.
DESIRED SKILLS AND EXPERIENCE:
Aggressive learner and self-starter, committed to self-development
Persistent, persevering and results driven
Ability to be flexible and able to adjust to high volume environment
Skilled at logical and creative thinking and ability to test information
Familiarity with investigative techniques, such as interviewing and evidence collection
Strong organization and communication skills
Strong mentoring skills
CAREER DEVELOPMENT:
It’s not just a job, it’s a career, and we are here to support you every step of the way. We want you to be successful and fulfilled. Through on-the-job experiences, personalized coaching and our robust learning and development programs, we encourage you â at every level â to grow and develop.
BENEFITS:
We offer comprehensive benefits to help you be healthy, build financial security, and balance work and home life. At The Hanover, you’ll enjoy what you do and have the support you need to succeed.
Benefits include:
Medical, dental, vision, life, and disability insurance
401K with a company match
Tuition reimbursement
PTO
Company paid holidays
Flexible work arrangements
Cultural Awareness Day in support of IDE
On-site medical/wellness center (Worcester only)
Click here for the full list of Benefits
EEO statement:
The Hanover values diversity in the workplace and among our customers. The company provides equal opportunity for employment and promotion to all qualified employees and applicants on the basis of experience, training, education, and ability to do the available work without regard to race, religion, color, age, sex/gender, sexual orientation, national origin, gender identity, disability, marital status, veteran status, genetic information, ancestry or any other status protected by law.
Furthermore, The Hanover Insurance Group is committed to providing an equal opportunity workplace that is free of discrimination and harassment based on national origin, race, color, religion, gender, ancestry, age, sexual orientation, gender identity, disability, marital status, veteran status, genetic information or any other status protected by law.â
As an equal opportunity employer, Hanover does not discriminate against qualified individuals with disabilities. Individuals with disabilities who wish to request a reasonable accommodation to participate in the job application or interview process, or to perform essential job functions, should contact us at: HRServices@hanover.com and include the link of the job posting in which you are interested.
Privacy Policy:
To view our privacy policy and online privacy statement, click here.
Applicants who are California residents: To see the types of information we may collect from applicants and employees and how we use it, please click here.
