Primary Purpose:

Identify and investigate questionable claims/risks and deliver facts and assistance to internal and external customers. Provides investigative assistance within the region and technical direction and support with complex SIU investigations

Essential Duties and Responsibilities:

Following is a summary of the essential functions for this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

• Assist SIU manager with duties to include special projects


• Establish an investigative plan on a daily basis


• Receive referral, communicate with referring sources, verify need for investigation and document all appropriate information


• Initiate investigation by gathering facts and evidence with all interested parties


• Complete appropriate reports


• Run appropriate database checks


• Take recorded statements when necessary


• Netmap referrals as necessary


• Hire appropriate experts with coordination of claim rep and supervisor and document investigative activity


• Complete both inside and field investigative tasks


• Work with vendors in setting expectations and resolving questions raised through the investigation


• Track and document the quality of service provided by defense counsel and forensic experts and manage vendor costs


• Evaluate facts and determine applicable laws


• Determine state fraud reporting requirements; summarization of investigative findings


• Identify answers to more complex issues with insurance law by reading and interpreting case law


• Provide training to internal and external customers


• Serve as mentor to SIU field investigators


• Periodic audit review of files by supervisor or management


• Conducts internal investigations regarding defalcation and employee misconduct issues as assigned

Minimum Skills and Competencies:

The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Bachelor's Degree or in-lieu of degree equivalent education, training and work-related experience


• Possess a solid understanding of insurance law as it relates to claims and SIU files


• Ability to interpret and apply investigative findings to determine action plan


• Possess effective verbal and written communication skills


• Ability to successfully perform in a high-energy, dynamic and team-oriented environment


• Possess effective organization and time management skills with the ability to work under pressure and adhere to project deadlines


• Possess excellent interpersonal skills with the ability to establish working relationships with individuals at varying levels within the organization


• Ability to demonstrate integrity within a professional environment


• High degree of initiative, mature judgment, and discretion


• Ability to handle confidential information in a professional manner


• Possess a general understanding of the insurance industry, organizational relationships of the company and the functions of other departments such as Policy Operations and Marketing


• Ability to manage conflict resolution


• Ability to travel up to 10%

Desired Skills:

• 7+ years of experience with a law enforcement agency and/or multi-line claims handling experience within the insurance industries


• Possess prior experience in the investigation of insurance fraud


• Successful completion of one or more professional designations: FCLS (Fraud Claims Law Specialist), CFE (Certified Fraud Examiner), CIFI (Certified Insurance Fraud Investigator)


• Higher Educational Degree (Master's Degree)