Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia
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Job Description
Investigator II handling insurance fraud investigations for West Bend, focusing on various personal, commercial, and specialty lines. Collaborating with internal stakeholders and external partners to evaluate and investigate suspicious transactions.
Responsibilities:
- Investigate suspected insurance fraud involving auto, property, casualty, workers’ compensation, and other personal, commercial, and specialty lines of business.
- Collaborative with internal stakeholders and external partners to evaluate and investigate suspicious insurance transactions (claims, underwriting, policy, etc.), collect evidence, support fraud detection programs, and communicate investigative findings to internal and external partners, regulators, and law enforcement.
- Support fraud detection and investigation by identifying red flags, gathering facts, and documenting evidence in compliance with company policy and legal requirements.
- Review claim files for basic red flags (inconsistencies, late reporting, coverage anomalies, questionable damages, medical billing issues).
- Apply checklists, referral criteria, and scoring tools to determine whether further investigation is warranted.
- Conduct thorough investigations of suspect insurance claims on moderate to high complexity cases with minimal supervision.
- Meticulous attention to detail to ensure accuracy and thoroughness in investigations and ensure efficient and effective investigations are completed using the most appropriate method of investigation through either field, desktop, or combination thereof.
- Evaluate, coordinate, and recommend investigative action plans in collaboration with claims, underwriting, and legal partners.
- Coordinate and monitor outside vendor activity related to assigned SIU investigations.
- Prepare detailed investigative reports for internal decision-making; support referrals to law enforcement or legal action when necessary, and where applicable to state fraud bureaus.
- Stay informed on regulations and statutes as well as internal protocols and procedures.
- Maintain thorough documentation of investigative actions and work products in accordance with accepted SIU operating standards and best practices.
- Serve as a subject matter expert for claims and/or Underwriting Department training on the detection, deterrence, and prevention of fraud.
Requirements:
- 6-8 years of fraud investigation, claims investigation, SIU support, or related research/analyst experience or equivalent combination of education and experience.
- Well-developed skills in evidence gathering and interviewing with demonstrated ability to follow investigative processes and best practices are essential.
- Clear written and verbal communication skills, including the ability to summarize complex findings; collaborative mindset and commitment to continuous learning as tools, regulations, and fraud tactics evolve.
- Proficient with investigative databases and standard office software.
- Ability to proficiently use computers and software for data entry, digital tools for research, and investigative analysis; digital photo/video documentation of loss scenes and evidence.
- Analytical and problem-solving Skills
- Interpersonal Skills
- Knowledge of fire cause and origin
- Valid driver’s license required; ability to travel within assigned territory
Benefits:
- Medical & Prescription Insurance
- Health Savings Account
- Dental Insurance
- Vision Insurance
- Short and Long Term Disability
- Flexible Spending Accounts
- Life and Accidental Death & Disability
- Accident and Critical Illness Insurance
- Employee Assistance Program
- 401(k) Plan with Company Match
- Pet Insurance
- Paid Time Off
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