Claim Investigator - Personal Lines

The Auto Club Group (ACG) provides membership, travel, insurance and financial services offerings to approximately 9 million members and customers across 11 states and 2 U.S. territories through the AAA, Meemic and Fremont brands. ACG belongs to the national AAA federation and is the second largest AAA club in North America.

Primary Duties and Responsibilities (details of the basic job functions):

Independently perform comprehensive assessment and investigation of personal lines property & casualty claims for the potential of claim fraud. Maintain a thorough understanding of insurance policies and claim handling practices and procedures, as well as insurance policy eligibility and underwriting requirements. Maintain a comprehensive understanding of claim fraud, including the fraud scenarios and methods by which insureds, claimants, service providers, and other parties may engage in opportunistic fraud, and also the ways in which businesses, professionals and organized crime groups, such as fraud rings, operate. Understand and comply with state laws, regulations, and case law impacting claim fraud and investigation activities.

Contact the claim representative assigned to the claim, work with them collaboratively, and keep them informed throughout the claim investigation. Review claims to identify the potential fraud scenarios that might be present, both for claim fraud and also policy premium fraud. Complete investigative activities that will help prove or disprove the presence of fraud.

Investigative activities may include identifying insureds, claimants, witnesses, service providers, and other parties and completing interviews or recorded statements. Obtain customer records such as utility bills and other documents pertinent to the investigation and when necessary with the permission of the insured. Complete vehicle inspections, home inspections, or conduct site-visits. Obtain and follow-up on public records, as well as police, fire and other official reports. Complete link analysis to understand the relationships between people, places, and things. Arrange for and attend Examinations Under Oaths. Obtain legal counsel opinion when necessary. Attend court hearings when necessary. Investigative activities may also involve hiring experts for specialized tasks such as home fire cause and origin analysis, surveillance, vehicle accident reconstruction, forensic accounting, and legal counsel, and managing those vendors through setting clear expectations, monitoring results, and reviewing and paying associated expenses. Complete investigations thoroughly but also balance expense costs against the facts and exposure of the claim.

Research and investigate fraud collaborators, fraud rings, and potentially fraudulent service businesses and professionals such as medical providers, body shops, attorneys or contractors. Understand and assess the implications of laws, licensing and practices related to those professions and their applicability to identifying and defending against policy and claim fraud.

Thoroughly document investigative activities, results, and evidence. Work collaboratively with law enforcement, other insurance carrier special investigation units, attorneys, and other parties. Prepare written investigative summaries, and report findings to the assigned claim handler, management, Underwriters and others.

Promote fraud awareness and expertise through liaison, consulting, collaboration, and training of company personnel when assigned.

Preferred Qualifications

Education:

  • Bachelor's degree in Business Administration, Insurance, Criminology or a related field or the equivalent in related work experience
  • Completion of The Institutes Associates In Claims (AIC), Chartered Property Casualty Underwriter (CPCU), or other insurance coursework
  • Fraud Claim Law Specialist Certification
  • Certified Insurance Fraud Investigator Certification

Experience:

  • Work experience in both claims handling as well as fraud investigation in Florida

Knowledge and Skills:

  • Medical injury treatment and medical provider practices as they relate to automobile accidents
  • Vehicle construction, repair estimation, repair and body shop industry practices
  • Home construction, repair estimation, repair and contractor industry practices

Work Environment

Works in a temperature controlled office environment. Occasional exposure to road hazards and temperature extremes.

Required Qualifications (these are the minimum requirements to qualify)

Education (include minimum education and any licensing/certifications):

  • College level coursework in Business Administration, Insurance, Criminology or a related field or the equivalent in related work experience. Bachelor's degree preferred.
  • Possession of a valid State Driver's License.

Experience:

Work experience including one of the following:

  • Five years of experience as a claim representative handling Auto or Home personal lines property and casualty insurance claims
  • Three years as an investigator in a claims special investigation unit that investigates fraud in personal lines property & casualty claims
  • Five years in law enforcement in roles such as detective, auto theft investigator, or arson investigator

Knowledge of at least one of the following:

  • Laws and regulations pertaining to insurance, claim handling, crime, and investigative activity
  • Auto and Home policy coverages, provisions, and eligibility and underwriting rules
  • Claim handling practices
  • Claim fraud scenarios and indicators
  • Fraud investigation techniques and practices

Ability to perform the following:

  • Communicate effectively with others in a work environment and with the public (e.g. Police department, vendors, contractors, attorneys, other insurance carrier special investigation units)
  • Analyze policies and claims for relevant provisions and applicability to the claim facts
  • Investigate claims, define appropriate evidence and obtain supportive documentation
  • Maintain and continually expend expert knowledge on claim fraud scenarios and indicators
  • Engage and manage experts to complete specialized tasks
  • Impart fraud awareness training in a formal or informal setting to other aaa employees, community groups or related professional organizations
  • Function effectively and independently in a personal computer environment utilizing word processing, spreadsheet and software systems
  • Present effective and persuasive testimony in civil and criminal litigation on a regular basis
  • Prepare and present effective written reports (a written sample may be required at time of interview)
  • Process complex, time sensitive data and information from various sources
  • Complete multiple complex tasks in a timely fashion and under deadline pressure while working on multiple cases simultaneously
  • Safely operate a motor vehicle

The Auto Club Group offers a competitive compensation and benefits package including a base salary with performance based incentives; medical/dental/vision insurance, pension, 401(k), generous time off, a complimentary AAA Membership and much more!

Important Note: The above statements describe the principal and essential functions, but not all functions that may be inherent in the job. This job requires the ability to perform duties contained in the job description for this position, including, but not limited to, the above requirements. Reasonable accommodations will be made for otherwise qualified applicants, as needed, to enable them to fulfill these requirements.

The Auto Club Group, and all of its affiliated companies, is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, disability or protected veteran status.


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