Investigator

• 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.

Investigator II handling insurance fraud investigations for West Bend

Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia

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.

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims.
• Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
• Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
• Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
• Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
• Attend and participate in regional FWA Task Force and other state or federal meetings.
• Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
• Ensure regulatory reporting is developed, accurate, and submitted timely.
• Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
• Develop and conduct internal FWA related training.
• Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
• Present and discuss case findings and recommendations in case review meetings with department and company management.
• Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
• Coordinate and manage the production of investigative materials in support of settlement negotiations.

Senior Investigator managing fraud, waste, and abuse audits at PacificSource

Senior Investigator

Senior Investigator managing fraud, waste, and abuse audits across independent teams at PacificSource. Conducting investigations and ensuring compliance with regulations and company policies.

• Independently conduct extensive and detailed investigations to determine origin & cause of fires and explosions
• Investigates assigned claims suspected of insurance fraud, including large fire loss and multiple claims
• Ensures that assigned cases are investigated and reported back according to best practices
• Anticipates training needs of customers based on customer exposure and antifraud initiatives
• Investigates site and provides expert testimony based on determination of origin & cause of fires
• Maintains assigned claims files in a confidential manner
• Reviews and makes recommendations on outcomes of investigations in a prompt manner
• Provides guidance and recommendations to claims leadership on claims resolution
• Develops and maintains rapport with government agencies and private information bureaus
• Identifies and interviews all witnesses or involved persons regarding incidents under investigation
• Independently concludes investigations and determines negligence and violation of laws

Senior Fire Investigator conducting fire origin and cause investigations

Senior Fire Investigator

Senior Fire Investigator conducting investigations to determine origin and cause of fires for EFI Global. Responsible for providing expert testimony and maintaining investigative integrity.

• Leads thematic, complex investigative projects and conducts sensitive investigations through analysis of evidence and digital forensics
• Collaborates with human resources, legal, and other business partners for investigative outcomes
• Engages with external law enforcement agencies as required
• Provides mentorship and training ensuring compliance with company, legal, and regulatory requirements
• Acts as the lead on high profile complex investigations and supports executive leadership teams.

Senior Lead Insider Threat Investigator leading complex investigations at TD Bank

Senior Lead Insider Threat Investigator

Senior Lead Insider Threat Investigator at TD Bank leading thematic and complex investigations while collaborating with multiple business partners and law enforcement.

Investigator jobs in North Carolina

See all jobs on JobTailor

Investigator II – Special Investigations Unit, Tennessee, North Carolina, Kentucky, Virginia

Senior Investigator

Senior Fire Investigator

Senior Lead Insider Threat Investigator