SIU PIP Investigator

📋 Description

• • Investigate and analyze complex Michigan Personal Injury Protection (PIP) claims referred to the Special Investigation Unit (SIU) for potential fraud, including both attorney-represented and unrepresented claims.
• • Conduct comprehensive background searches, scene investigations, and inspections of medical clinics, body shops, and loss locations to verify claim legitimacy.
• • Take recorded statements from claimants, witnesses, and medical providers as part of fraud investigations.
• • Review and analyze medical records, treatment notes, billing statements, and property damage documentation to identify inconsistencies or fraudulent activity.
• • Perform surveillance operations on property and individuals when necessary to gather evidence related to claims.
• • Conduct social media searches and online data application research to uncover corroborating or contradictory information regarding claims.
• • Validate the accuracy of all information obtained during investigations and follow up on all viable leads to ensure thorough case resolution.
• • Summarize investigation findings, document decision-making processes, and enter detailed notes into the claim system to maintain accurate and defensible claim files.
• • Review prior SIU investigations with fraud outcomes to validate the appropriateness of claim denials and ensure consistent adjudication standards.
• • Return claims to the Medical Claims Organization (MCO) for settlement when insufficient evidence of fraud is found or no fraud is substantiated.
• • Utilize analytic tools and SIU field intelligence to proactively identify high-risk claims requiring investigation and to support evidence-based fraud determinations.
• • Respond to complex customer communications, concerns, and conflicts related to PIP claims while maintaining compliance with state regulations and company policies.
• • Provide mentoring and coaching to less senior SIU staff, offering work guidance and direction to enhance team performance and investigation quality.
• • Enter accurate SIU claim data into multiple internal systems to ensure proper tracking, reporting, and audit readiness.
• • Apply sound judgment and a thorough analytical approach to assess whether fraud can be substantiated and whether litigation support is warranted.
• • Maintain a deep understanding of Michigan state PIP regulations and apply them consistently across all investigations.
• • Work in a fast-paced, remote environment while managing multiple high-priority cases with competing deadlines and shifting priorities.
• • Ensure all investigative activities comply with legal, ethical, and company standards for privacy, data handling, and due process.