PRINCIPAL SPECIAL INVESTIGATIONS UNIT (SIU) INVES - Los Angeles, CA

This listing closes on 5/9/2025 at 5:00 PM Pacific Time (US & Canada); Tijuana

• Supports Metro's Risk Claims Investigation administration as investigation leader by reviewing and analyzing claims for mitigation or claims identified to have red flags or suspicion of fraud, conducting highly complex investigations, communicating findings and recommendations to assist with claim management and mitigation, denial of fraudulent and abusive claims against Metro, and other investigation of related cases of employee misconduct
• The principal investigation position is assigned to the Special Investigation Unit responsible for investigation of Risk matters relating serious accidents or incidents
• The Principal Investigator's responsibilities may include but not limited to the following, claims documentation and mitigation strategies, administrative investigation and reporting, scene investigation to determine causation and/or reconstruction of accidents involving Metro vehicles and personnel
• Recruitment Timelines: Exams are projected to be scheduled for the week of May 18th, and interviews are projected to be scheduled for the week of June 1st
• We encourage you to monitor your governmentjobs.com profile and emails for the latest updates
• Conducts regular reviews of claims, analyzes information, and makes determinations of investigation path forward
• Plans, organizes, directs, and conducts complex investigations involving suspected workers' compensation fraud and abuse, insurance fraud, public liability fraud, administrative cases, and general criminal cases involving Metro; investigations may include covertly following personnel
• Serves as the principal project leader for contract firms by overseeing, monitoring, and reviewing work during claims investigations; reviews and approves invoices for payment; and audits performance of contractors
• Audits claims files using the Red Flag Assessment Program; investigates irregular findings of claim, Red Flags, or other identifiers
• Audits aging and new claim files using department processes for over $200,000 benefit appropriation and for adherence to procedures in processing
• Conducts intensive data mining reviews of information relating to claims/cases using multiple software data analysis systems to determine appropriateness for intensive investigation and surveillance
• Reviews case files which identify serial causation and recommends corrective action to resolve problems, abuses, and deficiencies
• Writes comprehensive, organized, and professional reports of investigation or policy recommendations
• Conducts investigation reviews, approves assignments or investigation
• Presents investigative findings, both orally and in writing, for determination of the prosecutorial merits of the investigation with Division or Labor Personnel, County Counsel, for concurrence before local government, and for state level reporting as required by law
• Reviews and approves investigation case files for employee hearings or external filing and reporting of suspected fraud to the local District Attorney's Offices, State Department of Insurance, and the State of California Fraud Division's Anti-Fraud Programs; prepares witnesses for court testimony and identifies evidence or obtains useful information to provide for defense of litigation
• Works with appropriate prosecution and law enforcement agencies, including State of California Department of Insurance, State of California Department of Industrial Relations Division of Workers' Compensation, and local District Attorney's Offices
• Testifies before the Workers' Compensation Appeals Board, courts, or at other administrative hearings regarding claim investigative findings
• Prepares and assists in the preparation of narrative, graphic, and statistical reports for executive and Board presentations, and internal review
• Develops policies and procedures for approval that will reduce the incidence of claim fraud and abuse or other recommendations identified as a result of investigative work
• Develops, implements, and presents Insurance Fraud Identification Training Program to Risk Management Claims Staff and Metro management personnel
• Mentors staff in matters of ethics, investigative techniques, case preparation, case strategy, techniques of court testimony, and appropriate legal preparation; keeps staff informed of current workers' compensation laws, rules, regulations, policies, and procedures
• Stays up to date on agency's current labor contracts, non-contract employee policies and procedures, workers' compensation laws, legislative changes, and case law determinations
• Complies with Metro's bill paying standards to ensure sub-contracted investigation firms are paid in a timely manner
• Responsible for communicating and implementing safety rules, policies, and procedures in support of the agency's safety vision and goals; and maintains accountability for the safety performance of all assigned staff
• Contributes to ensuring that the Equal Employment Opportunity (EEO) policies and programs of Metro are carried out
• May be required to perform other related job duties
• Communicating effectively orally and in writing
• Oversee, train, and motivate assigned staff
• Metro provides reasonable accommodation to enable individuals with disabilities to perform the essential functions
• Close exposure to computer monitors and video screen
• Exposure to hostile and armed criminal suspects
• Work irregular hours, split shifts, weekends, holidays, or 24-hour-a-day on-call assignments
• Work after designated regular hours in case of special assignments or emergencies
• Local travel
• Type and use a keyboard and mouse to perform necessary computer-based functions