Description
Insurance fraud investigators combat fraudulent activities by investigating the circumstances of certain suspicious claims, activities related to new customers, buying insurance products and premium calculations. Insurance fraud investigators refer potential fraud claims to insurance investigators who then undertake research and investigations to support or deny a claimant’s case.
Duties
The duties of an insurance fraud investigator include, but are not limited to:
- Conducting extensive and confidential investigations of suspected fraud allegations.
- Interviewing individuals who may have information on particular fraud allegations.
- Running background checks, employee investigations, and asset searches on suspected perpetrators.
- Analyzing documentation, such as victim testimonies and financial records to determine if fraud occurred.
- Writing in-depth reports on your findings and presenting them to management.
- Liaising with victims of fraud, the police, and court officials when a civil or criminal case is opened.
- Testifying on fraud cases in civil or criminal proceedings.
Other titles
The following job titles also refer to insurance fraud investigator:
insurance examiners
insurance fraud examiner
insurance fraud auditor
insurance policy processing worker
insurance policy processing workers
insurance fraud inspector
insurance inspectors
insurance auditors
Minimum qualifications
Usually, employers only require a high school diploma to work in the field. However, some employers may favor candidates with a college degree or relevant work experience. Many employers prefer hiring former police officers or private investigators.
The International Association of Special Investigation Units (IASIU), a professional association representing insurance investigators, recommends that aspiring insurance investigators obtain a college degree in business administration or criminal justice. Courses recommended to prepare investigators for the field include investigations, corporate crime, interrogations, accounting, insurance and business law.
ISCO skill level
ISCO skill level is defined as a function of the complexity and range of tasks and duties to be performed in an occupation. It is measured on a scale from 1 to 4, with 1 the lowest level and 4 the highest, by considering:
- the nature of the work performed in an occupation in relation to the characteristic tasks and duties
- the level of formal education required for competent performance of the tasks and duties involved and
- the amount of informal on-the-job training and/or previous experience in a related occupation required for competent performance of these tasks and duties.
Insurance fraud investigator is a Skill level 3 occupation.
Insurance fraud investigator career path
Similar occupations
These occupations, although different, require a lot of knowledge and skills similar to insurance fraud investigator.
loss adjuster
insurance claims handler
insurance risk consultant
property insurance underwriter
actuarial assistant
Long term prospects
These occupations require some skills and knowledge of insurance fraud investigator. They also require other skills and knowledge, but at a higher ISCO skill level, meaning these occupations are accessible from a position of insurance fraud investigator with a significant experience and/or extensive training.
insurance claims manager
insurance rating analyst
bankruptcy trustee
financial fraud examiner
actuarial consultant
Essential knowledge and skills
Essential knowledge
This knowledge should be acquired through learning to fulfill the role of insurance fraud investigator.
- Insurance law: The law and legislation concerning the policies of transferring risks or losses from one party, the insured, to another, the insurer, in exchange for a periodic payment. This includes the regulation of insurance claims and the business of insurance.
- Fraud detection: The techniques used to identify fraudulous activities.
- Principles of insurance: Understand the principles of insurance, including third party liability, stock and facilities.
- Actuarial science: The rules of applying mathematical and statistical techniques to determine potential or existing risks in various industries, such as finance or insurance.
- Claims procedures: The different procedures that are used to formally request a payment for a suffered loss from an insurance company.
- Types of insurance: The various types of risk or loss transfer policies that exist and their characteristics, such as health insurance, car insurance or life insurance.
Essential skills and competences
These skills are necessary for the role of insurance fraud investigator.
- Analyse claim files: Check the claim from a customer and analyse the value of the lost materials, buildings, turnover or other elements, and judge the responsibilities of the different parties.
- Review insurance process: Analyse all documentation related to a specific insurance case in order to ensure that the application for insurance or the claims process was handled according to guidelines and regulations, that the case will not pose significant risk to the insurer or whether claims assessment was correct, and to assess the further course of action.
- Assist police investigations: Assist in police investigations by providing them with specialised information as a professional involved in the case, or by providing witness accounts, in order to ensure the police have all relevant information for the case.
- Conduct financial audits: Evaluate and monitor the financial health, the operations and financial movements expressed in the financial statements of the company. Revise the financial records to ensure stewardship and governability.
- Assess customer credibility: Communicate with customers to assess whether their true intentions are in line with what they claim in order to eliminate any risks from a potential agreement with the customer.
- Interview insurance claimants: Interview people who have filed claims with the insurance corporation they are insured with, or through specialised insurance agents or brokers, in order to investigate the claim and the coverage in the insurance policy, as well as detect any fraudulous activities in the claims process.
- Detect financial crime: Examine, investigate, and notice possible financial crimes such as money laundering or tax evasion observable in financial reports and accounts of companies.
Optional knowledge and skills
Optional knowledge
This knowledge is sometimes, but not always, required for the role of insurance fraud investigator. However, mastering this knowledge allows you to have more opportunities for career development.
- Debt systems: The processes needed to obtain goods or services before payment and when a sum of money is owed or overdue.
Optional skills and competences
These skills and competences are sometimes, but not always, required for the role of insurance fraud investigator. However, mastering these skills and competences allows you to have more opportunities for career development.
- Collect property financial information: Collect information concerning the previous transactions involving the property, such as the prices at which the property had been previously sold and the costs that went into renovations and repairs, in order to obtain a clear image of the property’s value.
- Trace financial transactions: Observe, track and analyse financial transactions made in companies or in banks. Determine the validity of the transaction and check for suspicious or high-risk transactions in order to avoid mismanagement.
- Manage claim files: Follow up on the progress of a claim file, keep all parties informed of the status of the file, ensure the customer receives the damages owed, treat any problems or complaints from customers, close the file and give information to an authorised person or department when there is suspicion of fraud.
- Present evidence: Present evidence in a criminal or civil case to others, in a convincing and appropriate manner, in order to reach the right or most beneficial solution.
- Prepare financial auditing reports: Compile information on audit findings of financial statements and financial management in order to prepare reports, point out improvement possibilities, and confirm governability.
- Interpret law: Interpret the law during the investigation of a case in order to know the correct procedures in handling the case, the specific status of the case and the parties involved, the possible outcomes, and how to present the best arguments for the most favourable outcome.
- Obtain financial information: Gather information on securities, market conditions, governmental regulations and the financial situation, goals and needs of clients or companies.
- Document evidence: Document all evidence found on a crime scene, during an investigation, or when presented in a hearing, in a manner compliant with regulations, to ensure that no piece of evidence is left out of the case and that records are maintained.
- Perform debt investigation: Use research techniques and tracing strategies to identify overdue payment arrangements and address them
- Manage claims process: Manage the relation with an insurer related to its obligation to receive, investigate and act on a claim filed by an insured.
- Analyse financial risk: Identify and analyse risks that could impact an organisation or individual financially, such as credit and market risks, and propose solutions to cover against those risks.
- Classify insurance claims: Process incoming claims in order to assess their nature and categorise them according to the different types of insurance and claims handling procedures, in order to ensure proper administrative handling, and to guarantee that the claim may proceed to the correct loss adjuster or other claims professionals.
ISCO group and title
3315 – Valuers and loss assessors
References
- Insurance fraud investigator – ESCO
- Insurance Fraud Investigator: Salary and Career Facts – Learn.org
- Fraud Investigator Job Description – Betterteam
- Featured image: Photo by cottonbro studio from Pexels