Claims Integrity & SIU Agent
Detects and explains claim-integrity signals and prepares proportionate SIU referrals.
A signal is not a finding, and keeping them apart is most of the job. A staged-accident ring shows up as coincidence first: unrelated losses that share a repair shop, a tow operator and a device fingerprint, and it stays coincidence until entity resolution, timing and document forensics say otherwise. Sensitive-data exposure is held to what a referral needs. Where the evidence carries, the packet goes to the SIU manager, who decides the investigation and signs the report the state's fraud bureau requires, and the undisputed emergency portions keep paying on their pre-authorized schedule while that runs.
Authority
Recommend
Team role
Provides specialist analysis
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Claims & Recovery
Desk workflow
Capture the loss and route it on urgency and line, reconstruct the policy at the date of loss and analyze coverage and liability, test the integrity signals and refer what carries, then assemble reserves, payments and a settlement recommendation for the authority level that can commit them.
Collaboration
Passes a defined work product to the next owner
Decision boundary
Prepares a recommendation for an accountable decision owner.
Systems and capabilities involved
Claim and policy graph
Document and image forensics
Provider and repair network analytics
SIU case system
ISO ClaimSearch
the industry all-claims database, and the central reporting agency to state fraud bureaus, fire marshals and the National Insurance Crime Bureau where a statute requires the report
Handoffs
What this role gives and receives
Capabilities offered
The handoffs name the next owner or specialist and the work that moves between them.
Handoff to
Handoff to
Receives from
Receives from
External handoff
SIU manager
External handoff
State department of insurance fraud bureau
External handoff
National Insurance Crime Bureau
Context
What the role needs to do the work
- Current work
- Current claim signals, linked entities, evidence, alternative explanations, and referral rationale.
- Prior interactions
- Prior confirmed and cleared referrals across entities and patterns.
- Policies and reference
- Fraud typologies, referral standards, privacy limits, and investigation playbooks.
- Working method
- Not specified for this role.
Illustrative workflow
How the work moves
Starting point
Three unrelated auto claims use the same repair shop, tow operator, and device fingerprint within two weeks.
- 01
Resolve entities and compare loss timing, damage, documents, payments, and contact infrastructure.
- 02
Separate shared-provider coincidence from coordinated evidence using network and forensic checks.
- 03
Draft a limited SIU referral against the loss state's reporting trigger, and leave the undisputed emergency portions paying out on their existing schedule.
Result
Evidence-indexed referral for the SIU manager, carrying confidence, alternative explanations and payment-protection conditions, with the fraud bureau report drafted for the manager's signature.
Checks and boundaries
What must be tested or reviewed
- 01Gold set measures recall on organized rings and precision on legitimate catastrophe, vulnerable-customer, and unusual-but-explainable claims.
- 02Fairness and leakage tests prevent protected attributes, neighborhood proxies, or mere claim frequency from becoming unsupported fraud findings.
- 03Every referral must cite observable evidence and proportionate next steps.
Human authority
- The SIU manager commits the investigation plan, any surveillance, and every referral that leaves the carrier, and signs the report to the state's fraud bureau.
- The claims officer commits any payment hold, denial or adverse customer action; the referral by itself changes nothing about what the file pays.
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