SIU Fraud
Perez Investigations Inc. SIU (Special Investigations Unit) provides specialized investigative and advisory services on moderately complex situations involving questionable, suspect or fraudulent claims activity.
Our SIU investigators will work with law enforcement and other related agencies to investigate potential fraud. Investigators work under limited supervision to perform work assignments and problem resolution. SIU investigators will participate in the development of fraud prevention strategies and independent complete investigations.
- Evaluates claim fact patterns and develops work plans to reconcile issues
- Receives and evaluates information about fraud schemes and trends
- Reviews initial referrals, evaluates claim and underwriting information to identify appropriate assignment level and investigative strategies
- Contributes to the development of any and may present verbal and written investigative and management reports
- Collaborates with team members to resolve issues and to identify appropriate issues for escalation
- Acquires and applies intermediate knowledge of state laws and regulations pertaining to insurance fraud
- Acquires and applies working knowledge of insurance industry products, services & processes to include insurance policy contracts & coverage’s, and claim handling process & procedures
- Develops and maintains external relationships with industry, law enforcement and other contacts involved in fraud investigation, detection and prevention
- The SIU Specialist will demonstrate integrity, confidentiality, good judgment and solid decision making abilities
- Testify in the related court proceedings
- Provide services to include review of the incoming referrals of suspicious claims, gather all relevant information, strategize the case and develop recommendations for case handling
- Receives entire claim from the claims examiner and conduct initial review and analysis
- Organize the file into the following categories:
- Red flag checklist
- Transaction summary/medical bills paid
- Medical reports sorted by date and body part
- AME/QME Reports
- Deposition summaries
- Depositions
- Communications
- Correspondence
- Attorneys/Client privilege correspondence
- AOE/COE reports
- Sub-Rosa reports and video