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.
- 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).
- 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.
How much does a Fraud Specialist make near United States?
Base Pay
Additional Pay
$48,554
/ yrFraud 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.
Years of Experience Distribution
Fraud Specialist Insights
“Salary was pretty good but not super competative but profit sharing one a year was nice perk”
Grange Insurance“There’s a great culture and events but because volume is so high I have never been able to attend.”
State Farm“Great training and resources will be setup to do your job with confidence and continuous improvement.”
State Farm“Be prepared to do your work and the work of others for little or no recognition.”
Sedgwick“we are told to do many things ourselves that are really tasks for support staff.”
Envision Healthcare“This is a good starting point but not the company you'd want to retire at.”
Navient“Low pay for experience needed Say you will get bonuses but near impossible to aquire.”
Chase“training is provided for career mobility however this means actual career mobility can be extremely competitive.”
Frequently asked questions about the roles and responsibilities of a Fraud Specialist
- Claims Analyst
- Claims Adjuster
- Claims Examiner
- Claims Manager
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How much of a pay cut would you entertain to stay WFH, or work at an office 15 minutes away from your house? I moved companies during COVID, was told verbally my position would be remote, now starting to get pressure to go in the office and have a feeling it’s going to be mandatory multiple days a week, it’s a 50 minute commute. My prior company wants me back, is local and I really enjoyed working there. I don’t know how much they’d offer but I know they can’t match my bonus.