Major Case Specialist

The Major Case Specialist is responsible for the action planning, objective investigation, documentation and scheme resolution of potentially fraudulent claims that involve organized criminal enterprises. The types of claims that are investigated by the Major Case Specialist are with a primary but not exclusive focus on large-scale, highly complex collusive activity by multiple parties and/or deliberate fraud by professional/business entities. The Major Case Specialist provides direction to SIU Investigators on single claim investigations when related to a multi-faceted Major Case investigation and will provide proactive deterrence and complex fraud control solutions to Senior Management. The Specialist will make recommendations to SIU and claims leadership on the pursuance of civil remedies against parties/business entities that have received illicit financial benefit from Progressive.

SCOPE:
With minimal oversight the Major Case Specialist works in collaboration with claims management and legal for the purpose of an accurate claim and scheme resolution. The Major Case Specialist works independently to formulate and employ an investigative strategy in the highest complex fraudulent claim scenarios. The Major Case Specialist develops their caseloads through intelligence gathering, proactive analysis and direct business referrals. Case development will include high level due diligence of the fraud risk to determine if the potential fraud threat merits Major Case pursuit.

This position may also be assigned to a centralized investigative team that is tasked with the investigative resolution of potential fraud perpetrated by property damage repair vendors that are part of the Progressive Property Damage Network.

DUTIES & RESPONSIBILITIES:
Investigation (75%)
- Identifies and triages current and historical claims that require Major Case Specialist involvement.
- Interviews all parties material to the investigative purpose.
- Complete Examinations Under Oath (venue specific) without direct supervision
- Performs investigative fieldwork to verify information and/or investigative leads
- Utilizes appropriate investigative tools (i.e. databases, informational resources and public records) to verify information and/or identify investigative leads.
- Assigns and manages investigative vendors that are necessary to investigative resolution.
- Identifies relevant coverage issues during the course of the investigation.
- Sets and executes strategies for handling multiple claims investigations, including identifying links between claims and parties.
- Works with the Data Intelligence Group (DIG) and other sources to gather and analyze relevant data to identify trends and patterns of complex multiple party/entity fraud risk.

Communication/Consultation (25%)
- Communicates and documents investigative conclusions material to claim and scheme resolution.
- Makes formal reports to law enforcement and regulatory authorities where required.
- Packages proven organized claim fraud activity for prosecution presentation and acts as the liaison to law enforcement and prosecutorial agencies.
- Works with prosecutorial and regulatory authorities to receive restitution for illicit payments made to multiple related parties and/or business entities.
- Networks with industry personnel, law enforcement, legal counsel, and others to develop information for organized enterprise claim fraud activity.
- Provides investigative direction to other SIU Investigators on single claim's investigations that are related to Major Case activity.
- Provides fraud awareness, investigative consultation and mentorship to claim representatives and other investigators.
- Serves as a subject matter expert and may assist in the development and/or presentation of anti-fraud and SIU training.
- Makes recommendations to Senior. Management and legal on potential civil remedies related to proven multiple related claims fraud.
- Makes recommendations to Senior Management on proactive deterrence methods and control solutions.
- Serves as Progressive's point of contact on local, regional and/or national task forces related to large-scale complex multiple party/entity fraud investigations.
- Consults with outside counsel on investigative strategies related to complex multiple party/entity fraud investigations.

KNOWLEDGE, SKILLS & EXPERIENCE:
- Minimum of 7 years of relevant experience as an investigator. Relevant experience includes prior employment as a SIU Investigator, Law Enforcement or Regulatory Investigator or considerable experience as an investigator in the private sector.
- Advanced investigative experience with a history of investigating deliberate fraud schemes.
- Advanced interviewing proficiency
- Proficiency of detecting patterns of fraudulent activity among multiple claims.
- Advanced analytical skills, particularly with respect to link analysis of the business, personal, financial or loss history relationships of individuals or business entities.
- Experience in developing and presenting packages for civil and/or criminal prosecution.
- Excellent case management, communication and presentation skills.
- Excellent understanding of claims process and procedures.
- Strong inter-personal skills
- Strong verbal/written communication skills.
- Demonstrated team player.

WORK CONDITIONS:

The demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands:
- Must be able to maneuver to perform various fieldwork objectives (canvasses, vehicle inspections and facility inspections).
- Must be able to use various pieces of office equipment potentially for extended periods of time (computer screen, keyboard, mouse, phone, etc).
- Light lifting, carrying a laptop computer, and potentially extended periods of sitting or standing may also be required.

Work environment:
- The Major Case Specialist is based out of a Progressive Claims office; however, often this position requires visiting customer residences/neighborhoods, medical clinics, attorney offices, body shops, other business/government offices, other claims offices, salvage yards, and other vendors as needed in the course of business.
- May also work out of a company vehicle. The vehicle may be equipped with an on board printer, camera, and other investigative tools.
- Hours worked may be non-traditional, including evenings and weekends.
- Use of a company-provided cell phone will also be expected during office hours.
- Travel will be required in this position up to 50% of the time.
- Major Case Specialists assigned to a centralized SIU team may be required to travel in excess of 50% of the time.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform job related tasks other than those specifically presented.