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Claims Investigator

Job Summary

Responsible for handling claims that have triggered red flags or that companies suspect are fraudulent. Investigates claims to uncover criminal activity, false claims, staged accidents, or unnecessary medical treatments.

Primary responsibilities

  • Investigate suspicious insurance claims, including those that are suspected to have stemmed from fraud, criminal activity, arson, falsified documents, or unnecessary medical procedures.
  • Consult police and hospital records.
  • Consult with accountants, architects, construction workers, engineers, lawyers, and physicians to get expert evaluation.
  • Examine photographs and statements.
  • Listen to or watch audio or video surveillance.
  • Record data and statements in report.
  • Obtain background information on claimants and witnesses using a universal database.
  • Access personal information and identify Social Security numbers, aliases, driver's license numbers, addresses, phone numbers, criminal records, and past claims histories.
  • Search for previous cases of fraud.
  • Visit claimants to obtain oral statements.
  • Inspect facilities and determine if doctors hold proper licenses and certifications.
  • Perform surveillance work to determine if a claimant is performing rigorous activity that would rule out injuries in workers' compensation claim.
  • Take photos and document suspicious activity.
  • Report all activity to insurance company for final determination.
  • Testify in court cases when claimant is accused of fraud.

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