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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00019930 |
Description Activated On: 9/24/2025 11:24:22 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. In accordance with Act 44, all insurance companies must develop an anti-fraud plan. This position provides technical assistance and participates in SWIF’s anti-fraud plan. Assists in the prevention, identification, and investigation of insurance fraud and abuse involving workers’ compensation claimants, policyholders, vendors, and medical providers. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Assists SWIF’s Fraud Investigator in the identification and investigation of potential fraud and abuse involving the workers' compensation system. Gathers facts and evidence. Collects and examines documents and records (such as claims forms, payroll files, bank records, medical claims, and tax documents) from claimants, policyholders, medical providers, vendors, and other organizations to clarify or verify data related to investigations. Prepares for and conducts preliminary interviews of individuals involved. Reviews financial records and other documents from claimants, policy holders, vendors, and medical providers. Identifies questionable or inconsistent information, flags items for suspected fraud or abuse. Makes preliminary determinations of fraud and abuse and recommends next steps to lead investigator. Reviews referrals contained on the New Employee with Active Payment Plan Report; identifies whether a claimant’s commencement of employment has been properly reported to SWIF. Interacts with other SWIF staff (such as Claims Adjusters), other Commonwealth agencies (such as Department of Revenue), and law enforcement entities to request information and collect data related to investigations. Utilizes the Pennsylvania Justice Network (JNET) to identify and verify dates of incarceration and death. Schedules and gives instructions to private investigators and surveillance companies to assist with investigations, as directed by supervisor. Responds to inquiries regarding status of investigations, using discretion regarding the appropriate level of detail to share. Compiles and analyzes data related to allegations, investigative activities, and outcomes; prepares reports of case load and productivity, trends in types and numbers of cases, and related matters. Prepares summary reports of investigative findings and gathers supporting documentation for referrals to SWIF’s legal staff for approval of criminal charges or civil complaints, as directed by lead investigator. Assists lead investigator in identifying control system weaknesses. Maintains and updates case files and databases. Performs related duties as required. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Independently carries out assigned components of investigations, receiving direction and guidance from lead investigator. Prioritizes tasks to accomplish stated objectives. Determines the appropriate types and scope of information to collect related to an investigation and whether information gathered is sufficient to draw conclusions. Decides the appropriate approach to accomplish tasks based on precedent, facts and circumstances, and general office guidelines. Makes preliminary determinations of fraud and abuse and recommends next steps. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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