Position Summary:

Develop and conduct special investigations of claims on all warranted claims. Confirm claim validity or to identify fraud. Determines whether to refer a claim to the applicable department of insurance, the National Insurance Crime Bureau (“NICB”), and/or law enforcement. It provides underwriting risk advice. Assists consults with and advises the Claim employees and the Agency Force in recognizing and resisting fraudulent claims.

Prepares and conducts fraud awareness/resistance training. Establishes and maintains liaison and cooperation with public and private organizations charged with prevention, detection, and prosecution of insurance fraud. Coordinates and directs the efforts of contracted private investigators. Makes recommendations regarding the retention of experts, private investigators, and other expenditures.



Principal Duties & Responsibilities:

The following is a summary of the primary responsibilities of the position.

• Determines whether SIU involvement in the claim file is necessary, in accord with established guidelines, and will add value to the claim process.


• If SIU involvement is not appropriate, it recommends to the SIM that the file be removed from the Tracker system. Evaluates the entire claim, not only the unit being referred, for potential fraud indicators.


• Determines, analyzes, and describes the claim fraud indicators that warrant SIU involvement, and communicates them to the applicable claim’s professional assigned.


• Uses his/her judgment to determine how to conduct the investigation in a manner appropriate to the issues presented, outlines the investigative tasks that he/she will conduct to resolve the issues, and explains why he/she decided to conduct those tasks.


• Develops and conducts investigations into large or complex losses as well as other investigations. Coordinates the efforts of internal and outside resources in the investigation of complex and unusual claims situations.


• Responsible for using sound investigative techniques in compliance with all federal, state and local laws pertaining to investigations and fair claims-handling practices.


• Investigations may involve the use of sound recording devices. As the investigation develops, determines whether changed circumstances or newly discovered information warrant a change to the investigation plan, including adding additional tasks or deciding that certain tasks need not be performed.


• Explains why he/she changed the investigative plan and described the remaining tasks to be completed. Determines whether to refer a claim to the applicable department of insurance, the NICB, and/or law enforcement and advises the claims representative accordingly.


• Describes to the claims examiner the standard for referring a claim and the basis for the determination regarding referral. Uses appropriate judgment in providing underwriting risk advice.


• Takes ownership of the risk advice and ensures that any issues are reported as needed. Recommends retention of experts or private investigators, surveillance, or other expenditures.


• Provides support and training to other claims personnel through, among other things, trend and operational analyses, formal training classes, and informal training.


• Attends industry-recognized intelligence meetings Case preparation for Law Enforcement


• Adhere to Federal and State laws and regulations.


• Any other duties needed to help fulfill the Associations Mission, abide by the Association’s Values and fulfill the Association’s Strategic Objectives.

• High school diploma or equivalent required. Bachelor’s degree preferred.


• Minimum of 2 years’ experience in Subrogation and SIU environment.


• Decision making and problem-solving skills, both written and verbal communication skills and ability to work independently.


• Knowledge of claims operations and handling.

• High school or equivalent (Preferred)

• One location

• Health insurance


• Dental insurance


• Vision insurance


• Retirement plan


• Paid time off


• Professional development assistance


• Tuition reimbursement