What does a Fraud Specialist do?

Claims representatives work for insurance companies to settle claims through the evaluation of facts of a customer's situation surrounding their claim. They are responsible for determining whether the loss is covered and what compensation should be. They investigate thoroughly to ensure that an insurance claim is not fraudulent and may be required to contact relevant third-parties including a doctor, an employer, or to consult with a police report. Ultimately, claims representatives negotiate insurance settlements, authorize payments, and keep records.

Claims representatives serve as the liaison between a policyholder and an insurance specialist and are often the initial point person for insurance-related events. In some instances, they collaborate with representatives from other insurance companies for an incident that is relevant to both industries, including medical and automotive carriers. Claims representatives need a minimum high school diploma or GED and complete a college degree program that provides academic training for the vocation. Professional certification is also available.

What responsibilities are common for Fraud Specialist jobs?
  • Coordinate investigative efforts ensuring appropriateness. provide thorough review of contested claims.
  • Research problem claims accounts, reverse and reprocess as necessary.
  • Responsible to help work special projects with respect to overpayments.
  • Summarize claims in excess of authority and submit to manager for approval.
  • Create a estimate of damages for 1st and 3rd party material damage.
  • Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature.
  • Ensure that claims payments are issued in a timely and accurate manner.
  • Mentor and provide leadership to less experienced claims associates.
  • Assist with file reviews and file audits as needed.
  • Provide support to claim staff on client specific teams.
  • Inspect damages and prepare written estimates of repair or replacement.
  • Under limited supervision, responsible for making accurate decisions on specialty claim settlements.
  • Determine exposure, establish adequate reserves and make timely adjustments as required.
  • Partner with special investigation unit and subrogation to identify fraud and subrogation opportunities.
  • Apply appropriate interventions and follow up on identified projects.
  • Stay informed of changes in the collision repair industry as well as statutory and regulatory changes as they relate to material damage and communicate these changes to other claims personnel.
  • Determine company liability of COB claims based on COB rules and other insurance processing.
  • Take action independently, seek new opportunities, and strive to see projects to completion.
  • Assist the assistant director for administration with the preparation of financial statements and operating reports.
  • Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome.
  • Meet and communicate with claimants, legal counsel, and third-parties.
  • Timely and accurate filing and billing of all patient transactions (billing, invoices, and insurance claims).
What are the typical qualifications for Fraud Specialist jobs?
  • Bachelor's or Graduate's Degree in business or computer science. Certification in claims.
  • A natural collaborator with solid negotiation and decision making skills.
  • Demonstrated attention to detail and work ethic.
  • Use critical thinking alongside professionalism throughout scope of work.
  • Dedicated to running a quality program.
  • Demonstrated business acumen.
  • Fluent in liabilities and other practices.
  • Experience with R language and computing.
Work/Life Balance
3.3 ★
Total Pay--
Career Opportunity
3.3 ★
Avg. Experience8+ years

How much does a Fraud Specialist make near United States?

$48,554 /yr
Total Pay

Base Pay


Additional Pay


 / yr
Most Likely Range
Possible Range
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Fraud Specialist Career Path

Learn how to become a Fraud Specialist, what skills and education you need to succeed, and what level of pay to expect at each step on your career path.

Fraud Specialist

Years of Experience Distribution

0 - 1
2 - 4
5 - 7
Not including years spent in education and/or training

Fraud Specialist Insights

Read what Fraud Specialist professionals have to say about their job experiences and view top companies for this career.
Safety Engineering Consultants
Claims Representative
Oct 20, 2021

“Salary was pretty good but not super competative but profit sharing one a year was nice perk”

Grange InsuranceGrange Insurance
Outside Property Claims Representative
Apr 3, 2023

“There’s a great culture and events but because volume is so high I have never been able to attend.”

State FarmState Farm
Claim Associate
Jun 21, 2021

“Great training and resources will be setup to do your job with confidence and continuous improvement.”

State FarmState Farm
Fire Claim Specialist
Jul 13, 2022

“Be prepared to do your work and the work of others for little or no recognition.”

Senior Claims Representative
Aug 11, 2021

“we are told to do many things ourselves that are really tasks for support staff.”

Envision HealthcareEnvision Healthcare
Reimbursement Specialist
Jul 1, 2022

“This is a good starting point but not the company you'd want to retire at.”

Insurance Specialist III
Jan 12, 2023

“Low pay for experience needed Say you will get bonuses but near impossible to aquire.”

Senior Fraud Specialist
Jul 28, 2023

“training is provided for career mobility however this means actual career mobility can be extremely competitive.”

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Fraud Specialist Interviews

Frequently asked questions about the roles and responsibilities of a Fraud Specialist

The most similar professions to Fraud Specialist are:
  • Claims Analyst
  • Claims Adjuster
  • Claims Examiner
  • Claims Manager

Related Careers

Claims Analyst
No skills overlap
Claims Adjuster
No skills overlap
Claims Examiner
No skills overlap
Claims Manager

Fraud Specialist Jobs