SENIOR SPECIAL INVESTIGATIONS UNIT (SIU) INVESTIGATOR (RISK MANAGEMENT CLAIMS ADMINISTRATION)

Risk Claims Investigator

Supports Metro's Risk Claims Investigation administration by reviewing and analyzing claims for mitigation or claims identified to have red flags or suspicion of fraud, conducting highly complex investigations, and communicating findings and recommendations to assist with claim management and mitigation, denial of fraudulent and abusive claims against Metro, and other investigation of related cases of employee misconduct.

Plans, organizes, and conducts complex investigations involving suspected workers' compensation fraud and abuse, insurance fraud and other internal employee related administrative investigations as assigned; serves as project leader to contract firms when conducting and sub-contracting claims investigations; investigations may include covertly following personnel; conducts red flag assessment of injury / illness occupational claims and investigation of suspected falsified documents presented to Metro by employees or others; conducts intensive data mining reviews of information and social media relating to injured workers' using multiple software data analysis to determine appropriateness of intensive investigation and surveillance requirements; recommends corrective action to resolve problems, abuses, and deficiencies that may exist; presents investigative findings both orally and in comprehensive professional reports for determination of the prospective merits of an investigation with Division or Labor Personnel, County Counsel and concurrence before local government and state level reporting; prepares suspected case file for employee hearings or external filing and reporting of suspected fraud to the local District Attorney's Offices, State Department of Insurance, and the State of California Fraud Division's Anti-Fraud Program; testifies before the Workers' Compensation Appeals Board, courts, or administrative hearings on results of claims or investigations; conducts training for Claims Unit personnel and all other interested personnel with respect to fraud awareness and recognition; provides guidance to staff regarding complex investigations and case development; assists in preparing narrative, graphic, and statistical reports for executive and Board presentations, and internal review; develops policies and procedures directed at reducing the incidence of claim fraud and abuse; communicates and implements safety rules, policies, and procedures in support of the agency's safety vision and goals; and maintains accountability for the safety performance of all assigned employees.

A combination of education and / or experience that provides the required knowledge, skills, and abilities to perform the essential functions of the position. Additional experience, as outlined below, may be substituted for required education on a year-for-year basis. A typical combination includes : Education : Bachelor's Degree in Criminal Justice, Law, Public Administration, Business Administration, Political Science, or a related field; Experience : Three years of relevant experience in any of the following areas, workers' compensation investigations, administrative investigations, criminal investigations, fraud investigations, law enforcement, internal investigations, insurance fraud, risk management claims, or other similar investigations; some positions in this class may require specialized experience in area of assignment; Certifications / Licenses / Special Requirements : A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions; Designation or credentialing in workers' compensation as a field investigator or data mining social media investigator preferred; Certified Professional in Fraud Identification (CPFI), insurance fraud investigator, private investigator, or law enforcement training in investigation preferred.

Knowledge of (defined as a learned body of information that is required for and applied in the performance of job tasks) : Theories, principles, and practices of criminal rules of evidence, constitutional rights, search and seizure procedures, court procedures to be followed in criminal matters, formal hearings, and administrative actions; Applicable local, state, and federal laws, rules, and regulations governing insurance code, labor code, criminal investigations, and workers' compensation fraud and abuse recognition; Specialized investigative techniques, intelligence gathering, and interrogation methods; Skill in (defined as the proficient manual, verbal, or mental utilization of data, people, or things) : Conducting complex workers' compensation fraud, administrative, and criminal investigations; Preparing comprehensive reports and correspondence; Analyzing situations, identifying problems, and recommending solutions; Exercising sound judgment and creativity in making conclusions; Communicating effectively orally and in writing; Interacting professionally with various levels of Metro employees and outside representatives; Ability to (defined as a present competence to perform an observable behavior or produce an observable result) : Compile and analyze complex data; Understand, interpret, and apply laws, rules, regulations, policies, procedures, contracts, budgets, and labor / management agreements; Drive a vehicle; Travel to offsite locations; Available to work at varied shifts and start times; Read, write, speak, and understand English.