• Broad knowledge of Aflac products and procedures, policy data, benefit plans, company terminology, medical terminology, and in-house coding systems

• Knowledge of Aflac systems

• Excellent oral, written, and interpersonal communication skills to effectively interact with internal and external customers, and agency representatives collecting or providing information

• Beginning progress toward one or more of the following designations/certifications: Fraud Claims Law Specialist (FCLS) or Health Care Anti-Fraud Associate (HCAFA)

• Basic knowledge and skills in Microsoft Word and Excel

• Proficient in Microsoft Access and Outlook

Education & Experience Required

• High School Diploma or Equivalent
• Three years of related work experience in one of the following areas: Claims, Customer Call Center – Claims, New Business, New Account Set-Up

Or an equivalent combination of education and experience

Principal Duties & Responsibilities

• Receives suspect documents from workflow; logs referrals into the Special Investigative Unit (SIU) case management system; obtains additional information as needed to determine if a full investigation must be performed; accepts or rejects the suspect claim after initial review within established time frame; enters remarks in the Claims Processing System (CPS); completes status letters to e policyholders about pended claims

• Performs basic data research and establishes files to assist team members with possible fraud investigations, including but not limited to retrieving documents from imaging and requesting medical records, payroll documents, authorization forms etc.; schedules appointments for the investigators to meet with involved parties (physicians, associates, suspect, local police, DOI, etc.); requests check copies and uses system programs (ACL, Easytrieve, Business Objects) to extract and analyze reports and other documents; prepares investigation status reports and other ad hoc reports for management

• Enters investigative data into the SIU database; maintains confidential, effective, and accurate online records, databases, or filing systems that provide a quick-reference source for information on fraud investigations, policies, procedures and other department activity; acts as the department’s customer contact, answering routine questions about department services, events, procedures, and policies if needed or refers questions to appropriate team members

• Tracks the progress of the investigation, sends status update letters to policyholders as required by state law; calculates restitution amount based on the investigation results; prepares restitution letters for review; coordinates with other affected business units as necessary

• Initiates reviews of calls pertaining to claims from the fraud hot line; reviews trend reports for claims filed by line of business; conducts preliminary reviews to determine if the claims are legitimate

• Prepares requests received by the Department of Insurance(DOI) and pulls all relevant information (Claims, Checks, EOB’s) from the appropriate systems; process information for mailing to DOI; keys relevant information received in case management system for investigators reference; prepares letters to policyholders for restitution payments received each week; reviews and ensures cases are investigated in a timely manner

• Provides administrative support to manager and SIU team members with check requests for vendors, training, and other expenditures; makes travel and meeting arrangements, and completes expense reports in SAP; provides general administrative support to the business unit

• Performs other duties as required

Total Rewards

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions including, but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. The range has been created in good faith based on information known to Aflac at the time of the posting. Compensation decisions are dependent on the circumstances of each case. This salary range does not include any potential incentive pay or benefits, however, such information will be provided separately when appropriate. The salary range for this position is $33,000 to $76,000.

In addition to the base salary, we offer an array of benefits to meet your needs including medical, dental, and vision coverage, prescription drug coverage, health care flexible spending, dependent care flexible spending, Aflac supplemental policies (Accident, Cancer, Critical Illness and Hospital Indemnity offered at no costs to employee), 401(k) plans, annual bonuses, and an opportunity to purchase company stock. On an annual basis, you’ll also be offered 11 paid holidays, up to 20 days PTO to be used for any reason, and, if eligible, state mandated sick leave (Washington employees accrue 1 hour sick leave for every 40 hours worked) and other leaves of absence, if eligible, when needed to support your physical, financial, and emotional well-being. Aflac complies with all applicable leave laws, including, but not limited to sick and safe leave, and adoption and parental leave, in all states and localities.