Claims Special Senior Investigator - Field

Job Summary:

The Claims Special Senior Investigator is responsible for handling commercial and personal lines investigations of moderate to high technical complexity with limited supervision. Conducts moderate volume investigations typically requiring outside investigation, including but not limited to in-person recorded statements, neighborhood canvases, and scene inspections. Acts as a resource/subject matter expert (SME) to other SIU investigators and field claims personnel. Develops and maintains positive and effective business relationships with SIU-related vendors, including officials, surveillance vendors, governmental agencies, etc.

Job Responsibilities:

• Conducts or supervises quality independent, in-depth investigations of questionable or suspicious claims and completes and communicates timely, detailed, and accurate investigative reports on assignments.
• Initiates appropriate civil and/or criminal proceedings on all applicable claims that have the potential of being deemed as fraudulent in nature.
• Develops and maintains positive and effective business relationships with vendors, including officials, surveillance vendors, governmental agencies, etc.
• Determines appropriateness and feasibility of external investigations, and coordinates assignments to external vendors for investigations, such as social media, medical provider canvases, and surveillance.
• Maintains effective and ongoing communication with claims staff, internal and external business partners, insureds, claimants, agents, attorneys, other insurance companies, project team members, claims leadership, and vendors. Shares knowledge gained with others and is responsible for driving new and updated policies, processes and procedures.
• Remains current on industry topics, trends, processes, technology, best practices through research, industry events, networking, etc.
• Investigates claims of questionable nature with potential arson or fraud related concerns, covering all lines of business involving insureds, claimants, agents, brokers, attorneys, medical providers, etc.
• Performs in-depth investigation to develop sufficient evidence to assist the claims professional and recommend a final course of claim action.
• Develops and documents information on any investigation, file review, audit, training assignment, or other project as directed by writing detailed reports of their findings.
• Reports appropriate claims and investigative reports to state and local authorities and NICB, including those claims that meet NICB questionable database guidelines. Submits appropriate monthly reports to leader.
• Collects, safeguards and analyzes evidentiary information from various sources.
• Presents information and data to cross-functional stakeholders to educate and raise fraud awareness and prepares and presents detailed reports to leadership.
• May partner with Learning and Development to design and conduct professional courses and fraud awareness training for clients and employees.
• Testifies and provides evidence at administrative and criminal court proceedings as required, collaborates with other special investigative units and fraud related organizations to support their proceedings as required and offers expert advice to personnel regarding investigations.
• Leader Assistance - May direct staff and/or substitute for a leader.
• Travels as often as needed including regular utilization of assigned fleet vehicle in order to cover assigned territory. This may involve traveling on short notice or other daily driving duties as assigned, regardless of location.

Job Qualifications:

• 5-7 years of experience in Claims Handling and/or Investigative Experience.
• Bachelor's degree in Business Administration, Insurance or related field and/or commensurate work experience.
• For field roles only: Valid driver's license and a driving record that conforms to company standards.

Location:

Remote

Licenses and Certifications:

• Certified Insurance Fraud Investigator (CIFI) (preferred)

Behavioral Competencies

• Collaborates
• Communicates Effectively
• Customer Focus
• Decision Quality
• Nimble Learning

Technical Skills:

• Investigative Procedures
• Fraud Investigation
• Claims Handling
• Fraud Detection
• Claims Investigation
• Insurance Industry Knowledge
• Technical Documentation
• Data Analysis and Reporting
• Claims Management System

This job description describes the general nature and level of work performed in this role. It is not intended to be an exhaustive list of all duties, skills, responsibilities, knowledge, etc. These may be subject to change and additional functions may be assigned as needed by management.