Description
Conduct thorough investigations of insurance claims to verify coverage, liability, and potential fraud. Gather and analyze evidence, interview involved parties, and produce factual reports that support settlement, denial, subrogation, or litigation in accordance with company policies and legal requirements.
- • Lead investigations on complex, high-exposure, or suspected fraud claims with high-touch file handling.
- • Recommend claim disposition and next steps within guidelines; escalate issues beyond authority.
- • Conduct deeper inquiry on adjuster-referred files to determine fraud risk and payment authorization.
- • Verify and analyze data used in settling claims to confirm claim validity and compliance with procedures.
- • Document investigative activities, evidence, and findings in claim systems with timely, concise notes.
- • Refer cases to SIU, legal, or law enforcement when indicators of fraud or criminal activity are present.
- • Collect, preserve, and catalog evidence to support contested claims in court, maintaining chain of custody.
- • Confer with legal counsel on litigated or potentially litigated claims and provide testimony support.
- • Contact or interview doctors, medical specialists, employers, or law enforcement to obtain additional information.
- • Maintain organized case files, evidence logs, and an inventory of investigations requiring detailed analysis.
- • Examine claim forms, policies, and records to verify coverage and loss details.
- • Analyze information gathered during investigations and report findings and recommendations.
- • Review police reports, medical records, bills, and property damage to assess liability and causation.
- • Inspect loss scenes, photograph evidence, and document damages; review repair estimates for accuracy.
- • Interview claimants, agents, and other parties to correct errors or omissions and probe questionable claims.
- • Obtain recorded statements from claimants, witnesses, and other sources to establish facts.
- • Investigate and evaluate claims to deliver clear, objective findings that support timely, fair decisions.
- • Provide reserve impact recommendations based on investigative findings, consistent with company policy.
- • Present cases and participate in discussions at claim committee or roundtable meetings.
- • Advise adjusters on investigative strategies, red flags, and documentation standards.
- • Conduct detailed bill and record reviews to identify anomalies, upcoding, or patterns indicating fraud.
- • Verify property ownership, liens, and titles or vehicle histories as part of claim validation.
- • Report overpayments, underpayments, misrepresentations, and other irregularities.
- • Collaborate with underwriting, subrogation, and reinsurance teams when findings affect coverage or recovery.
- • Prepare clear investigative reports, chronologies, and recommendations for internal stakeholders.
- • Perform background checks and open-source intelligence within legal and privacy guidelines.
- • Attend mediations, depositions, or trials and testify to investigative procedures and findings as needed.
- • Verify employment, income, and work status with employers or former associates when relevant to a claim.
- • Coordinate scene inspections, canvasses, and surveillance activity with internal or external resources.
- • Manage caseloads, deadlines, and travel schedules to meet service standards and regulatory requirements.
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
