Job Description

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Key Objectives

This role will be responsible for analyzing, evaluating, and determining the validity of insurance claims by conducting thorough investigations and working closely with stakeholders to ensure a fair and accurate resolution. This position works closely with country Claims teams and Regional Fraud & SIU team.

Duties and responsibilities

• Conduct investigations of suspicious and potentially fraudulent claims to identify any irregularities and inconsistencies.
• Gather and examine evidence using various investigative techniques and tools (like FIS 2.0 or Merimen Fraud tool or Internal Fraud checklist and detection tools) to verify submitted claims and uncover fraudulent activity.
• Work closely with internal and external stakeholders such as claimants, policyholders, law enforcement agencies, and insurance providers to gather information and evidence.
• Prepare, file, and maintain accurate and complete reports on claim investigations, fraud trends, and losses.
• Develop and implement strategies and procedures to prevent, detect, and mitigate fraudulent activities.
• Collaborate with other departments within the organization to identify weaknesses, gaps, and opportunities to improve existing processes and procedures.
• Stay up to date with the latest industry trends, laws, and regulations concerning claims fraud and continuously improve knowledge and skills.
• Testify in court or administrative hearings as an expert witness in cases related to fraud investigations, claims, and settlements.
• Leads or actively participates in training claim handlers to create fraud awareness.
• Provide support to the rollout of COG and regional fraud initiatives.

• Excellent analytical and critical thinking skills
• Strong attention to detail and ability to work independently and in a team environment.
• Ability to maintain confidentiality and exercise discretion in handling sensitive information.
• Ability to identify areas of improvement to prevent fraudulent claims.
• Excellent written and verbal communication skills.
• Proficient in Microsoft Office Suite and other investigative software/systems.

• 5-10 years of relevant experience in conducting fraud investigations and resolving claims disputes, preferably in the insurance industry.
• Knowledge of laws, regulations, and investigative techniques related to insurance fraud.

• Bachelor\'s degree in criminal justice, business administration, or related field

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