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Bristol West - Sr Special Investigator


Job Summary

This role is responsible for determining validity of moderately complex and high exposure claims and/or identifying fraud. Conducts investigations using proven investigative techniques in compliance with all federal, state and local laws pertaining to insurance claim investigations and fair claims- handling practices.

Essential Job Functions

Conducts claim investigations using advanced investigative techniques in compliance with all federal, state and local laws pertaining to insurance claim investigations and fair claims-handling practices. Investigations may involve interviews and statement taking, use of photographic and sound recording devices, investigative field work, contact with law enforcement, social media and other background checks, as well as other investigative methods and activity of complexity. Coordinates the efforts of outsourced investigative entities and experts. Evaluates moderately complex and large exposure claims for potential industry recognized fraud indicators; provides recommendation and support as to whether SIU involvement in the claim file is necessary in accord with established guidelines; analyzes and documents the claim fraud indicators that warrant SIU involvement, communicates with claim owner, and collaborates on the development of an investigation plan tailored to the needs of the file. Proactively monitors investigation development to determine whether changed circumstances or newly-discovered information warrant a change to investigation plan, including adding additional investigative activity or determining certain investigative activity initially planned for is no longer needed. Documents and supports why the investigative plan changed and outlines the remaining tasks to be completed. Proactively communicates and collaborates with assigned claim owner during the investigative cycle. Completes accurate and professional investigative claim file documentation to include scheduled investigation status updates; reports findings of investigations to key claims stakeholders. Provides professional and experienced testimony in legal proceedings when needed. Provides recommendations regarding the retention of experts, private investigators, and other expenditures. Follows prescribed compliance regulations to determine on when to report a claim to the NICB, applicable state Department of Insurance and/or other Law Enforcement Agency. Describes to claims personnel the standard for reporting a claim and the basis for the determination regarding reporting. Follow established guidelines to provide underwriting risk advice; takes ownership of the risk advice and ensures all issues discovered are reported. Attends conferences, arbitration hearings as necessary. Delivers training, formal and informal, to claims and agency force personnel in fraud recognition, investigation and resistance. Establishes and maintains relationships and cooperation with public and private organizations charged with prevention, detection and prosecution of insurance fraud. May provide support to entry level investigators through trend and operational analyses, formal and informal training, and assignments. May assist People Leader with general employee support and development, and administrative tasks as needed.

Physical Actions

Sits or stands for extended periods of time, up to a full work shift. Occasionally reaches overhead and below the knees, including bending, twisting, pulling, and stooping. Occasionally moves, lifts, carries, and places objects and supplies weighing 0-10 pounds without assistance. Listens to, interprets, and differentiates auditory information (e.g. others speaking) at normal speaking levels with or without correction. Visually verifies and reads information. Visually locates material, resources and other objects. Ability to continuously operate a computer for extended periods of time, up to a full work shift. Physical dexterity sufficient to use hands, arms, and shoulders repetitively to operate keyboard and other office equipment up to a full work shift.

Physical Environment

This position operates in an open office working environment which will include normal and customary distractions, noise, and interruptions.

Education Requirements

High school diploma or equivalent required. Bachelors degree preferred.

Experience Requirements

Minimum two years of claims experience required. Minimum one year of experience in an investigator role preferred. Or three years experience in a law enforcement environment required.

Special Skill Requirement

Additional Qualification

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