Claim Investigator (CSIU)

AAA-The Auto Club Group•MI-Admin Office Building (AOB), MI

7d•$67,000 - $87,000•Remote

About The Position

The Auto Club Group is seeking a highly skilled Claim Investigator who would be responsible for reviewing and investigating insurance claims to determine their validity, accuracy, and compliance with company policies and regulatory requirements. They gather and analyze evidence, interview claimants, witnesses, medical providers, and other involved parties, and examine documentation such as police reports, medical records, and property damage assessments. Their goal is to identify potential fraud, verify claim details, and support fair and timely claim resolutions.

Requirements

College level coursework in Business Administration, Insurance, Criminology or a related field or the equivalent in related work experience.
Possession of a valid State Driver's License.
A valid driver's license is required if the primary responsibilities of the role involve conducting in-person inspections or frequent in-person meetings with members.
In states where an Adjuster’s license is required, the candidate must obtain within 90 days.
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 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)
Ability to analyze policies and claims for relevant provisions and applicability to the claim facts
Ability to investigate claims, define appropriate evidence and obtain supportive documentation
Ability to maintain and continually expend expert knowledge on claim fraud scenarios and indicators
Ability to engage and manage experts to complete specialized tasks
Ability to impart fraud awareness training in a formal or informal setting to other AAA employees, community groups or related professional organizations
Ability to function effectively and independently in a personal computer environment utilizing word processing, spreadsheet and software systems
Ability to present effective and persuasive testimony in civil and criminal litigation on a regular basis
Ability to prepare and present effective written reports (a written sample may be required at time of interview)
Ability to process complex, time sensitive data and information from various sources
Ability to complete multiple complex tasks in a timely fashion and under deadline pressure while working on multiple cases simultaneously
Ability to safely operate a motor vehicle

Nice To Haves

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
Work experience in both claims handling as well as fraud investigation.
Knowledge of medical injury treatment and medical provider practices as they relate to automobile accidents
Knowledge of vehicle construction, repair estimation, repair and body shop industry practices
Knowledge of home construction, repair estimation, repair and contractor industry practices

Responsibilities

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.

Benefits

PTO
paid sick leave
Medical plans with multiple coverage options, including HSA eligibility.
Prescription drug coverage.
Dental and vision benefits.
Employee Assistance Program (confidential support services).
Company-paid basic life insurance.
Optional supplemental life insurance and dependent coverage.
Short-term and long-term disability coverage.
Critical illness, accident, and pet insurance options.
401(k) plan to support long-term financial goals.
Company match of 50% paid on employee contributions up to 6% of pay, payable to employees following the end of the year; immediate vesting.
Additional company contribution of 4% of pay each pay day into your account; 100% vested after three (3) years of service.
Health Savings Account (HSA) and Flexible Spending Accounts (FSA) options.
Paid holidays:
Full-time new employees will receive up to 12 PTO days annually; accrual based on start date and may include additional PTO based on role and/or state & local requirements.
Part-time employee PTO hours are calculated based upon the standard weekly hours the employee is scheduled to work and will accrue at a minimum of 3 hours per month.
Full-time employees are eligible for 10 company-paid holidays annually, in addition to 1 mental health day, 2 floating holidays, and 1 volunteer day.
Part-time employees are eligible for 8 company-paid holidays annually, in addition to 1 mental health day and 2 floating holidays.
Paid leave programs, including parental, bereavement, jury duty, and military leave.
Tuition assistance (up to $5,250 annually; 80% covered by ACG).
Professional certification support with 100% reimbursement for eligible programs.
Opportunities for career development and advancement.
Complimentary AAA membership with roadside assistance and travel discounts.
Adoption assistance program.