Fraud Investigator Job Description

Investigation of Insurance Fraud

The type of industry the fraud occurs in often determines the approach that the investigators use. An investigator in medical billing practices must know what treatments are deemed necessary or questionable. An investigator must be open to all possibilities.

Insurance fraud cases can range from customers submitting false claims to companies using illegal methods to avoid honoring legitimate ones, as stated in "PI Now" magazine. The essential facts in a case may not be revealed immediately. The investigator summarizes his findings in a report for the client.

The report identifies how the fraud occurred, the estimated loss, and any responsible parties, according to Stephen Pedneault, author of "Anatomy of a Fraud Investigation". The investigator will recommend local law enforcement if the report supports a criminal case. Police may discuss the case with company representatives or individuals during an initial meeting, in which the investigator may also participate.

Resume Examples for a Fraud Investigator Job

Fraud investigators find relevance in a wide range of fields, from private establishments to government agencies and insurance companies, where they work to identify and resolve financial maneuvers. Fraud investigators work with other professionals such as law enforcement agents, legal attorneys and medical doctors to interpret evidence and help with the resolution of technical difficulties. The work experience part of your resume shows that you have experience working as a fraud investigator and can be trusted to succeed on the job. If you are creating a resume for a fraud investigator job, you can use the skills required for the job given above in making the skills section of the resume.

Healthcare Fraud Investigation: Formal and Electronic Records

Formal allegations are the first step in a healthcare fraud investigation. 40% of fraud detection comes from tips, with the majority coming from employees. A routine internal or external audit can uncover fraudulent activity.

The compliance department might be able to report allegations to management. Employees who are leaving may reveal fraud allegations during exit interviews. Fraud allegations could come from law enforcement.

Organizations should establish a method for individuals to report fraud allegations without fear of reprisal. Management or compliance teams should document and communicate any allegations they receive from employees. The investigative team should develop a comprehensive approach to analyzing financial, business, and electronic records that are applicable to the fraud investigation.

Data Scientists for Financial Crime Investigation

Financial crime investigations are getting more complex as a result of the changes that are on the horizon. The investigators will have a difficult time fighting the complexity of investigations. The use of case management systems and alert systems will be a thing of the past.

To handle the workload, more advanced and complex analytic tools are needed and financial crime departments will need data scientists and tools to weed out the mess and help investigators focus on the actual activities at which they are looking. If you work on a team that has different trained and skilled staff, you can get the best results. A data analyst is great finding anomalies, but they are not directly quantified as an investigator.

You need people with product or customer knowledge to merit anomalies. A great investigator should be open minded, curious, and versatile in order to perform at their highest level. It is important to maximize your abilities in order to maximize your investigator's job in the business.

An Internal or External Investigation of a Fraud

If you will use an internal or external investigator, you should decide that first. An internal investigator is inexpensive and gives you control over the investigation. An external investigator may be more expensive than your organization can afford, but they offer an impartial and objective perspective on the situation.

If there is a person who has reported a fraud, you should interview them. If the fraud was discovered by an auditor, interview them. If you have a reasonable factual basis for an investigation, you should determine it based on the information they give.

Contact other sources that can provide more information. If you can't reach an RFB or someone else can't, an investigation isn't appropriate. The key to stopping fraud is to detect it as soon as possible.

Passwords and locks can be changed to prevent further theft. If the alleged fraudster is a client or customer, suspend their account. You have to have a plan if you want your fraud investigation to be successful.

Get your team on the same page about the investigation. As the investigation progresses, your plan is subject to change. You should identify what you are trying to learn.

Understanding and Reasoning about Fraud Investigation

1. Understand the business. Fraud investigators need to understand the business side of information technology and work with software to be good.

Business rules and processes are needed to help with different types of fraud. 2. Understand the source of information.

When fraud investigators are looking for evidence, they should know whether the information is on the server or somewhere else. Knowledge of the inner workings of a company is important to know where to get needed information. 3.

Writing skills The reports of the findings of fraud investigators should be clearly and concisely put together. The investigator's report marks the end of a case, as it becomes expedient for the client to get feedback on the assignment.

There are 4. Active listening Fraud investigators should take time to understand what other people are saying and give full attention to what they are saying.

Certified Fraud Examiners

There are more possibilities for fraudulent activities as technology and communication advances. Fraud investigators help identify fraudulent activities and prevent them in the future. It is helpful to learn the process you need to complete to become a fraud investigator.

Fraud investigators are usually full-time employees. Some positions are part time or temporary. The salary of a fraud investigator will be dependent on a number of factors.

A high school degree is required for most entry-level fraud investigators. Some employers may require a bachelor's degree in accounting, criminal justice, business administration, fraud management or economic crime. There are specific requirements for each industry that employs fraud investigators.

Taking courses in forensic accounting and criminal justice will teach you how to investigate, fight, and prosecute fraud. Depending on the state you live in, licensure requirements will vary. You will have to comply with all the laws of the state you prefer to practice fraud investigation in.

You may have to take education courses and take an exam before you can get a license. Other states may require your employer to be licensed and allow you to work for a company that is not your own. Some states may require fraud investigators to take continuing education courses.

Online Certified Fraud Investigation

Fraud investigators work with prosecutors. Some people form their own companies and get hired to investigate fraud. Their hours might be irregular and include working nights and weekends.

Fraud involving electronic means has risen, leading to an increasing need for skilled fraud investigators. The CFE exam tests fraud investigators in various areas. You can take it online at any time, but you have to take it in one sitting and complete it in 30 days.

You have three attempts to pass each section. You must get 75% of the questions in each section to pass. To become a fraud investigator, you need to have a bachelor's degree in criminal justice, business administration, accounting, legal studies, fraud management or a related field.

If you have experience in finance, criminal justice, law, auditing, insurance or private investigation, you could be a good candidate for certification. To remain certified, certified fraud investigators must pay their annual membership fees and complete at least 20 hours of continuing education each year. There are a variety of learning opportunities at the ACFE.

Experienced Fraud Examiners

The possibilities for fraudulent activity using electronic medium has increased with the growth of technology. The need for experienced fraud investigators has grown. The investigators may work for the federal government, police departments, insurance agencies, banks, and healthcare organizations.

Some fraud examiners work for their own clients in private practice. Civil and criminal investigations are performed by fraud investigators. They investigate cases of insurance and credit card fraud, interviewing and working with postal officials when offenses have occurred through the mail.

People who have been affected by fraudulent activity are interviewed by investigators. They conduct research, serve and execute search warrants, and conduct surveille on transactions that are electronic to gather evidence of fraudulent activity. Fraud investigators work with prosecutors and attorney generals to present investigation results and testify in court.

Criminal investigations, background investigations, suspect business practices, and insurance casualty claims are some of the things that applicants with experience with will be most likely to be hired as a fraud investigator. A potential fraud investigator needs to have the ability to conduct interviews, take statements, write reports, and collect and preserve evidence. Fraud investigators must be ethical and good at communicating.