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Claim Investigation

Knowledge of claim investigation procedures and policies; ability to gather necessary information to determine damage, liability, compensation, adjustments and other case-specific issues related to claim investigation.

Behavior Statements

Proficiency Level 1 - Basic understanding

Clarifies the company's claim investigation processes and major approaches.

Describes the most critical points that need to be investigated when a claim is filed.

Identifies basic techniques needed to collect and diagnose the authenticity of relevant data.

Explains the relationships with claims adjusters, insurance companies, outside legal counsel, and other claims related parties.

Proficiency Level 2 - Working experience

Implements claim investigation processes; summarizes claim content.

Gathers appropriate documentation, forms of identification, medical certificates or loss proofs to effectively prepare for investigations.

Interviews participants and inputs data through a verification system.

Resolves typical problems that may arise during the investigation process; escalates more complex problems to senior staff.

Analyzes liabilities and the extent of claim being reported in common cases and defines their attributes.

Proficiency Level 3 - Extensive experience

Manages the entire investigation process from notification to resolution.

Anticipates conflicts or any complex issues when obtaining evidence from appropriate parties or institutions.

Advises others on whether and how much liability exists in complex cases.

Collaborates with other functions to handle claims outside of expertise.

Prepares and presents documentation for the defense.

Monitors applicable laws and regulations and shares them with the investigation team.

Proficiency Level 4 - Subject matter depth and breadth

Leads and coordinates the investigation for complex claims cases.

Constructs strategic partnerships with special investigation units or law firms.

Develops guidelines used to standardize investigation approaches for the organization.

Integrates investigation processes with recovery processes in order to streamline working standards.

Designs budgets for overall processes, based on coverage and investigation costs.

Establishes a professional legal team within the unit and prepares for legal issues.

Interview Questions

  • What kind of experience do you have working with special investigation units?
  • What kinds of tools did you use for processing or evaluating claims?
  • What kinds of problems have you encountered when preparing and presenting documentation for litigation?
  • Describe from your last few jobs whether or not management bought into the claims advice given and how that affected how you were able to successfully do your job?
  • Can you tell me about a particularly complex claim or dispute that ultimately had a successful resolution?

Titles with Shared Competencies