WHAT DOES A FRAUD INVESTIGATOR DO?

Published: Apr 11, 2025 – The Fraud Investigator conducts in-depth investigations into complex internal fraud cases, analyzes root causes, and applies findings to improve fraud detection systems. This position delivers high-quality reports to support disciplinary actions and legal proceedings while coordinating with law enforcement and legal entities. The investigator also implements and monitors fraud control improvements, proactively applying intelligence to strengthen risk management and operational resilience.

A Review of Professional Skills and Functions for Fraud Investigator

1. Fraud Investigator Overview

  • Fraud Analysis: Analyzes the merchant’s business activity based on alerts
  • Fraud Analysis: Analyzes transactions from a fraud perspective independently of alerts
  • Team Support: Assists other team members
  • Contract Termination: Operates contract termination process for merchants: prepares termination letters, collects signatures, issues relevant communication, and archives
  • Settlement Management: Blocks/unblocks settlements and POS terminals
  • Transaction Investigation: Does research regarding abnormal transactions, transaction patterns
  • Queue Management: Handles the error queue for the excessive refunds queue
  • Queue Management: Handles error queue for automatic block settlement
  • External Communication: Handles requests from external partners and authorities (e.g., Banks, issuers, third parties, police, etc.)
  • Internal Communication: Handles requests from internal stakeholders
  • Merchant Support: Handles requests from merchants
  • Case Allocation: Processes e-mail requests, promptly allocates cases

2. Fraud Investigator Additional Details

  • Case Management: Handle own allocation of cases and assess files from inception
  • Workflow Management: Control and manage workflow
  • Intelligence Gathering: Manage the investigations and intelligence gathering from a variety of sources
  • Stakeholder Communication: Interaction with service providers and stakeholders, including solicitors, to settle or repudiate claims accurately and at an optimum level
  • Investigation Process: Carry out investigations from first detection through to repudiation, settlement, and/or recovery stage
  • Research Skills: Conduct research and investigative searches using closed and open sources to develop intelligence and evidence
  • Evidence Collection: Gather evidence from various sources, including police reports, witness statements, and medical reports
  • Reporting: Report and log identified savings
  • Industry Engagement: Attend industry seminars and forums where applicable and relevant
  • Legal Awareness: Keep up to date with current trends and case law
  • Model Testing: Work with technical staff to test fraud models

3. Fraud Investigator Essential Functions

  • Report Writing: Produce high-quality investigation reports
  • Interviewing: Undertake 3 investigative interviews per day
  • Claims Processing: Ensure claims are processed according to Davies Group and client philosophies
  • Performance Achievement: Achieve consistent financial and productivity results in line with targets
  • Validation Enquiries: Conducting validation enquiries of customers and validation enquiries of claims with various third parties in the UK and overseas
  • Telephone Interviewing: Conducting investigative telephone interviews and reporting on the same
  • Training Support: Assist in the training and development of new staff
  • Data Accuracy: Ensure the accuracy of information in the database
  • Service Standards: Achieve service standards, contractual, and company requirements
  • Industry Engagement: Industry engagement to understand developments and trends, disseminating information internally to strengthen the Bank's fraud prevention and detection controls
  • Fraud Reporting: Deliver and maintain accurate and relevant fraud-related MI and reporting to meet the needs of governance committees and stakeholders at all organisational levels
  • Technical Documentation: Takes responsibility for tasks, such as technical writing, reporting, metrics, etc.

4. Health Fraud Investigator General Responsibilities

  • Lead Utilization: Utilizing leads provided by the investigative team and referrals from government and private agencies
  • Case Prioritization: Working with the team to prioritize complaints for investigation, and then investigating, conducting interviews, and reviewing information to make a potential fraud determination
  • Fraud Evaluation: Determining the investigation or case appropriateness of fraud, waste, and abuse issues following pre-established criteria
  • Referral Review: Reviewing and referring potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee
  • Interviewing: Conducting interviews of witnesses, informants, subject area experts, and targets of investigations
  • Evidence Handling: Maintaining information files and chain of evidence (identifying, collecting, preserving) and analyzing and summarizing evidence for supporting documentation of claims
  • Document Verification: Examining records, verifying the authenticity of documents, and providing information to support the preparation of attestations/referrals, or supervising the preparation of attestations/referrals
  • Investigation Reporting: Drafting investigation reports, evaluating investigation reports, and promoting effective and efficient investigations
  • Agency Communication: Initiating and maintaining communications with law enforcement and appropriate regulatory agencies
  • Case Presentation: Presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies
  • Legal Testimony: Testifying at various legal proceedings
  • Process Improvement: Identifying opportunities to improve processes and procedures
  • Customer Service: Providing a high level of customer service with internal and external communications

5. Fraud Investigator Responsibilities

  • Complex Investigation: Undertake investigations into complex and internal frauds that are sensitive, high profile, and/or of a high value nature across multiple disciplines, products, segments, and channels, highlighting root causes and trends to fraud systems analysts to direct analysis and rule changes
  • Fraud Oversight: Deliver ongoing and thematic Fraud Risk Oversight to plan and quality in line with Board Commitments
  • Thematic Reporting: Provide top-down thematic reporting and recommendations for further control developments
  • Control Remediation: Fraud control effectiveness and efficiency – drive and monitor remediation
  • Operational Failings: Fraud operational control failings – drive and monitor remediation
  • Report Writing: Producing high-quality investigation reports and outputs to support HR disciplinary and external law enforcement processes
  • Fund Recovery: Progress recovery of funds through asset tracing and invoking civil remedy measures on behalf of the Bank
  • Investigation Techniques: Maintain knowledge of investigative techniques, ensuring current
  • Legal Engagement: Engage with law enforcement and legal representatives, providing evidence to the requisite standard
  • Tool Development: Use and development of proactive fraud detection and analytical tools, testing new applications and exception reports, providing feedback and recommendations
  • Model Improvement: Drive fraud controls, risk management, and fraud operating model improvement
  • Oversight Planning: Feed investigation findings into the risk-based Fraud oversight plan for VMUK
  • Intelligence Gathering: Proactively gather, apply, and disseminate intelligence from internal and external sources to strengthen the Bank's fraud prevention and detection controls across systems, processes, procedures, and education
Relevant Information
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