Director of Special Investigations (Workers Compensation)
Company: Berkshire Hathaway Homestate Company group
Location: San Diego
Posted on: October 31, 2024
Job Description:
WHO WE AREBerkshire Hathaway Homestate Companies is dedicated to
being the best workers compensation insurance company by providing
compassionate care to injured workers, superior service to our
customers, and compelling opportunities for our employees. BHHC has
earned an enviable record of success and growth in the insurance
industry while growing a culture centered around inclusion and
collaboration. We pride ourselves on maintaining our small company
feel and recognize that attracting and retaining high quality
talent is essential to the success of our company.WHAT WE'RE
LOOKING FORThe Director of Special Investigations is responsible
for oversight of the Special Investigations Unit, ensuring
strategic direction and implementation of effective prevention,
detection, investigation, reporting, and recovery techniques to
mitigate company exposure related to fraud. This individual will
serve as a member of our Senior Leadership Team and work
collaboratively with fellow Claims, Medical Management,
Underwriting, Premium Audit, Finance, and Legal leadership to
leverage resources and drive innovative approaches to reduce
company losses.ONSITE REQUIREMENT (NON-NEGOTIABLE)This is a hybrid
opportunity with a minimum requirement of three days per work week
in our San Diego, CA office; Wednesday being a required all-hands
Collaboration Day.LEADERSHIP RESPONSIBILITIESThis position relies
on extensive experience, keen judgment, and strong leadership
skills to perform the functions of the job and achieve results in
established timelines. Takes a proactive approach to anticipating
and solving problems. Ensures that employees understand their level
of accountability and takes appropriate action to ensure employees
fully understand roles, responsibilities, and performance
standards, and provides ongoing feedback and support. Executes
responsibilities professionally and in accordance with the
Company's policies and applicable laws.ESSENTIAL
RESPONSIBILITIES
- Develops, directs and evaluates investigative strategies,
practices, policies and performance standards to ensure desired
outcomes are achieved in alignment with the department's mission
and operational goals. Instills operational discipline and ensures
adherence to company guidelines, policies, procedures and
compliance with applicable regulatory requirements.
- Collaborates with key Senior Leadership (Claims/Medical
Management, Underwriting, Premium Audit, Finance, Legal) to refine
and maintain SIU best practices and processes to prevent, detect,
investigate and ensure timely reporting of suspected fraudulent
activity.
- Creates and facilitates required fraud detection/prevention
training to company staff. Ensures timely, thorough recordation of
participation and completion is maintained and forwarded to proper
regulatory authority.
- Helps achieve successful investigative outcomes by providing
expertise and ensures the internal team and external defense
attorneys are providing appropriate legal support to assist in
attaining timely and effective outcomes. Ensures investigations are
conducted in compliance with applicable statutes, regulations, case
law, and company standards.
- Provides investigative support for Lien Unit and external
counsel as requested for litigation addressing issues associated
with suspected fraud or abuse of billing and reporting
practices.
- Leads efforts to partner with internal and external legal and
investigative resources to ensure successful strategic outcomes at
a competitive cost. Compiles data to monitor effectiveness of
outcomes and implements changes as needed to accomplish fruitful,
cost-effective results consistent with regulatory and industry
standards/trends and corporate objectives.
- Understands critical business goals and determines the talent
development needs within the team to support these goals. Aligns
with Human Resources and COO to attain top talent and ensure
continued engagement of team members via educational opportunities,
effective performance feedback, mentorship, recognition or
disciplinary action as necessary, and competitive
compensation.
- Participates as an accountable member of the Senior Leadership
Team and promotes company strategies and values.REQUIRED
QUALIFICATIONS
- EDUCATION/EXPERIENCE: Juris Doctor or minimum of Bachelors
degree in Criminal Justice, Psychology, Sociology, Business
Administration, Finance, or related major from an accredited
college or university; or, minimum of ten (10) years of relevant
experience in special investigations within workers compensation,
insurance fraud and abuse, or law enforcement, with a minimum of
five (5) years of progressive managerial experience directing
investigative personnel with complex workflows (e.g., regulatory
reporting); or, a combination of relevant education and industry
training and experience.
- CERTIFICATIONS/LICENSES: One or more of the following
preferred: Active license in good standing to practice law in one
or more jurisdictions; Certified Fraud Examiner (ACFE); Certified
Insurance Fraud Investigator (CIFI); Chartered Property Casualty
Underwriter (CPCU); Self-Insurance Certification (Claims/SIP).
- LANGUAGE ABILITY: Able to read, analyze, interpret and advise
regarding complex governmental regulations, legal opinions, claims
laws and regulations, technical claims processes and procedures
relating to fraud detection/prevention, and medical billing and
reports. Able to effectively present information and respond to
questions from Executive management, vendor partners, legal counsel
or authority, and the general public. Able to respond to technical
inquiries from internal and external sources, and regulatory
agencies.
- MATH AND REASONING ABILITY: Able to solve practical problems
and deal with a variety of variables in situations where only
limited standardization exists. Able to interpret instructions
furnished in written, oral, diagram, or schedule form. Relies on
extensive experience and judgment to plan and accomplish
goals.
- TECHNICAL AND COMPUTER SKILLS: Strong business and industry
regulatory acumen complemented by claims adjusting knowledge,
premium and medical billing familiarity, and industry best
practices in risk management and fraud detection/prevention.
Advanced communication and presentation skills with ability to
deliver complex information effectively to Executive management in
order to achieve objectives. Solid knowledge of Microsoft Office
applications and job-related proprietary software. Knowledge of
Power BI, SQL highly preferred.
- TRAVEL: Occasional travel to other corporate offices or vendor
locations required.In accordance with the California Equal Pay Act,
the pay scale for this job is $148,760 - $190,370. This pay scale
is an estimate of the salary range the employer reasonably expects
to pay for the position based on potential employee qualifications,
operational needs and other considerations consistent with
applicable law. The actual salary may be above or below the range.
The pay scale applies only to this position and only if it is
filled in California. The pay scale may be different for other
positions or in other locations.
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Keywords: Berkshire Hathaway Homestate Company group, San Diego , Director of Special Investigations (Workers Compensation), Human Resources , San Diego, California
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