Claim Investigator (CSIU)

About this role

Job Type:

Full time   Exempt/Non Exempt:  

Salary Job Description:

  Location Details: Remote

Position Schedule / Shift: Monday-Friday 8am-5pm ET

Position Summary:

The Auto Club Group is seeking a highly skilled Claim Investigator who would be responsible for reviewing and investigating insurance claims to determine their validity, accuracy, and compliance with company policies and regulatory requirements. They gather and analyze evidence, interview claimants, witnesses, medical providers, and other involved parties, and examine documentation such as police reports, medical records, and property damage assessments. Their goal is to identify potential fraud, verify claim details, and support fair and timely claim resolutions.

Key Responsibilities: • Independently perform comprehensive assessment and investigation of personal lines property & casualty claims for the potential of claim fraud. 

• Maintain a thorough understanding of insurance policies and claim handling practices and procedures, as well as insurance policy eligibility and underwriting requirements.

•  Maintain a comprehensive understanding of claim fraud, including the fraud scenarios and methods by which insureds, claimants, service providers, and other parties may engage in opportunistic fraud, and also the ways in which businesses, professionals and organized crime groups, such as fraud rings, operate. 

•  Understand and comply with state laws, regulations, and case law impacting claim fraud and investigation activities.

• Contact the claim representative assigned to the claim, work with them collaboratively, and keep them informed throughout the claim investigation. 

• Review claims to identify the potential fraud scenarios that might be present, both for claim fraud and also policy premium fraud. 

• Complete investigative activities that will help prove or disprove the presence of fraud. 

• Investigative activities may include identifying insureds, claimants, witnesses, service providers, and other parties and completing interviews or recorded statements. 

• Obtain customer records such as utility bills and other documents pertinent to the investigation and when necessary, with the permission of the insured. 

• Complete vehicle inspections, home inspections, or conduct site-visits. 

• Obtain and follow-up on public records, as well as police, fire and other official reports.

• Complete link analysis to understand the relationships between people, places, and things. 

• Arrange for and attend Examinations Under Oaths. 

• Obtain legal counsel opinion when necessary. 

• Attend court hearings when necessary. 

• Investigative activities may also involve hiring experts for specialized tasks such as home fire cause and origin analysis, surveillance, vehicle accident reconstruction, forensic accounting, and legal counsel, and managing those vendors through setting clear expectations, monitoring results, and reviewing and paying associated expenses. 

• Complete investigations thoroughly but also balance expense costs against the facts and exposure of the claim.

• Research and investigate fraud collaborators, fraud rings, and potentially fraudulent service businesses and professionals such as medical providers, body shops, attorneys or contractors. 

• Understand and assess the implications of laws, licensing and practices related to those professions and their applicability to identifying and defending against policy and claim fraud.

• Thoroughly document investigative activities, results, and evidence. 

• Work collaboratively with law enforcement, other insurance carrier special investigation units, attorneys, and other parties. 

• Prepare written investigative summaries, and report findings to the assigned claim handler, management, Underwriters and others. 

• Promote fraud awareness and expertise through liaison, consulting, collaboration, and training of company personnel when assigned. 

Qualifications:

Required

Education (including minimum education and any licensing/certifications): • College level coursework in Business Administration, Insurance, Criminology or a related field or the equivalent in related work experience. 

• Possession of a valid State Driver's License.

• A valid driver's license is required if the primary responsibilities of the role involve conducting in-person inspections or frequent in-person meetings with members.

• In states where an Adjuster’s license is required, the candidate must obtain within 90 days.

Experience:

Work experience including one of the following: • Five years of experience as a claim representative handling Auto or Home personal lines property and casualty insurance claims.

• Three years as an investigator in a claims special investigation unit that investigates fraud in personal lines property & casualty claims

• Five years in law enforcement in roles such as detective, auto theft investigator, or arson investigator.

Knowledge of at least one of the following:

• Laws and regulations pertaining to insurance, claim handling, crime, and investigative activity

• Auto and Home policy coverages, provisions, and eligibility and underwriting rules

• Claim handling practices

• Claim fraud scenarios and indicators

• Fraud investigation techniques and practices

Ability to perform the following:

• communicate effectively with others in a work environment and with the public (e.g. police department, vendors, contractors, attorneys, other insurance carrier special investigation units)

• analyze policies and claims for relevant provisions and applicability to the claim facts

• investigate claims, define appropriate evidence and obtain supportive documentation

• maintain and continually expend expert knowledge on claim fraud scenarios and indicators

• engage and manage experts to complete specialized tasks

• impart fraud awareness training in a formal or informal setting to other AAA employees, community groups or related professional organizati

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