Sample Job Description for Claim Compliance Investigation Director
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Claim Compliance Investigation Director Job Overview
Claim Compliance Investigation Director Job Description Sample
Directs the claims investigation function to detect, investigate, and prevent fraudulent or suspicious claims activity.
JOB LEVEL
M04
EDUCATION/DEGREE
Bachelor's Degree
REPORTS TO
Senior Management
Salary Range
BASE 50%
$154,090
TOTAL 50%
$179,890
Job Responsibilities for Claim Compliance Investigation Director
Oversees managers and investigators responsible for special investigations, surveillance, and fraud analysis. Develops investigation strategy, protocols, and standards aligned with legal and regulatory requirements. Analyzes fraud trends and investigative outcomes to inform prevention and recovery initiatives. Coordinates with legal counsel, law enforcement, and regulatory agencies on significant cases. Ensures compliance with applicable laws, regulations, and ethical investigative standards.
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View Job Description Templates of Similar Jobs
| Job Title | Job Description | |
|---|---|---|
| 1 | Vice President of Claims | The Vice President of Claims is responsible for managing and implementing claims programs for all lines of insurance. Plans and directs all aspects of an organization's insurance claims function. Being a Vice President of Claims develops procedures and policies to enhance and improve the processing, investigation, and settlement of claims. Directs the review and settlement of complex or high dollar claims. In addition, Vice President of Claims ensures legal examinations are made when appropriate. Requires a bachelor's degree. Typically reports to top management. The Vice President of Claims manages a departmental function within a broader corporate function. Develops major goals to support broad functional objectives. Approves policies developed within various sub-functions and departments. Comprehensive knowledge of the overall departmental function. Working as a Vice President of Claims typically requires 8+ years of managerial experience. |
| 2 | Claims Examinations/Adjustments Manager | The Claims Examinations/Adjustments Manager oversees the investigation, evaluation, negotiation, and settlement of claims to meet operational, financial, and service requirements. Manages the operations of an insurance claims department to ensure timely, accurate, and compliant claims handling. Being a Claims Examinations/Adjustments Manager reviews complex or high-exposure claims and provides technical guidance and settlement authority to staff. Develops and enforces procedures, quality controls, and performance metrics to maintain consistency and compliance. In addition, Claims Examinations/Adjustments Manager monitors caseloads, productivity, and reserve accuracy to meet departmental goals. Ensures compliance with applicable regulations, company policies, and customer service expectations. Requires a bachelor's degree. Typically reports to a director. The Claims Examinations/Adjustments Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Working as a Claims Examinations/Adjustments Manager typically requires 5 years experience in the related area as an individual contributor. 1-3 years supervisory experience may be required. Extensive knowledge of the function and department processes. |
| 3 | Claims Payment Clerk I | The Claims Payment Clerk I inputs claim information into system for processing. Reviews insurance claim forms and supporting documents for completeness and accuracy and obtains missing information as necessary. Being a Claims Payment Clerk I calculates settlement amounts according to guidelines. Verifies coverage eligibility. In addition, Claims Payment Clerk I processes routine claim payments. Requires a high school diploma or equivalent. Typically reports to a supervisor. Being a Claims Payment Clerk I works under the close direction of senior personnel in the functional area. Possesses a moderate understanding of general aspects of the job. May require 0-1 year of general work experience. |
| 4 | Strategic Sales Director | The Strategic Sales Director sets short- and long-term sales strategies and evaluates effectiveness of current sales programs. Directs and oversees an organization's sales policies, objectives, and initiatives. Being a Strategic Sales Director requires a bachelor's degree. Recommends product or service enhancements to improve customer satisfaction and sales potential. In addition, Strategic Sales Director typically reports to an executive. The Strategic Sales Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. Working as a Strategic Sales Director typically requires 5+ years of managerial experience. |
| 5 | Claims Service and Operations Director | The Claims Service and Operations Director provides guidance and sets policies on insurance claims for personal, property, or casualty loss based on coverage, appraisal, and verifiable damage. Directs and oversees the operations of an insurance claims department to meet operation, financial, and service requirements. Being a Claims Service and Operations Director keeps abreast of any changes to legislation and regulations which pertain to insurance claims. Responsible for the strategic processing and payment of claims. In addition, Claims Service and Operations Director provides guidance to subordinates on the most complex claims. Requires a bachelor's degree. Typically reports to top management. The Claims Service and Operations Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Working as a Claims Service and Operations Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. |
Claim Compliance Investigation Director Skills & Proficiency Level
| Skills | Proficiency Level |
|---|---|
| Planning and Organizing | Level 4 |
| Coordination | Level 4 |
| Conflict Resolution | Level 3 |