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Fraud Claims Operations Representative Jobs in Tennessee

MEM

Senior Claims Representative (Remote)

Columbia, TN · On-site +1

MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal ... Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.

HomeServe USA

Claims Analyst

Chattanooga, TN · Remote

The Contractor Operations Claims Analyst will be responsible for data analysis, reporting, and ... The physical demands described represent those that must be met by an employee to successfully ...

New

Contact Government Services, LLC

Auditor

Knoxville, TN

$80K - $100K/yr

Normalize claims data across several health benefit plans in order to perform a time study or other ... representatives to gather facts, identify sequence of events, and obtain statements and relevant ...

Charlie Health

Patient Account Representative

Nashville, TN · Hybrid

$17.50 - $23/hr

Support other RCM departments in identifying and analyzing open claims, as well as correct billing ... Please be cautious of potential recruitment fraud. If you are interested in exploring opportunities ...

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Fraud Claims Operations Representative information

What are the key skills and qualifications needed to thrive as a fraud claims operations representative, and why are they important?

To thrive as a Fraud Claims Operations Representative, you need strong analytical skills, attention to detail, and experience in financial services or fraud investigation, often supported by a relevant associate's or bachelor's degree. Familiarity with fraud detection software, case management systems, and banking platforms is typically required. Excellent communication, problem-solving, and customer service skills help you resolve claims efficiently and reassure affected clients. These skills are essential for accurately identifying fraudulent activity, mitigating losses, and maintaining customer trust in financial institutions.

How does a fraud claims operations representative typically collaborate with other departments during an investigation?

Fraud Claims Operations Representatives regularly work with teams such as Customer Service, Risk Management, and IT Security to thoroughly investigate and resolve fraud cases. Collaboration often involves sharing detailed case information, coordinating on account holds or restrictions, and ensuring that customers are kept informed throughout the process. Effective communication and teamwork are essential, as representatives must often escalate complex cases or seek specialized expertise from other departments to reach a resolution promptly.

What does a fraud claims operations representative do?

A Fraud Claims Operations Representative is responsible for investigating and resolving claims related to fraudulent activities on customer accounts. They review transaction details, communicate with customers to gather information, and determine the validity of reported fraud. Their work helps protect both the financial institution and its customers from financial losses due to unauthorized or suspicious activity. They also ensure compliance with company policies and legal regulations during the claims process.
What are popular job titles related to Fraud Claims Operations Representative jobs in Tennessee? For Fraud Claims Operations Representative jobs in Tennessee, the most frequently searched job titles are:
What job categories do people searching Fraud Claims Operations Representative jobs in Tennessee look for? The top searched job categories for Fraud Claims Operations Representative jobs in Tennessee are:
What cities in Tennessee are hiring for Fraud Claims Operations Representative jobs? Cities in Tennessee with the most Fraud Claims Operations Representative job openings:
Fraud Claims Operations Representative jobs near you

Senior Claims Representative (Remote)

MEM

Columbia, TN • On-site, Remote

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired today. Applications are no longer accepted.

Job description

Are you a seasoned claims professional with a passion for navigating complex cases? MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal role, you’ll manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and collaborate across departments to drive strategic outcomes. You’ll be a key decision-maker, a mentor to junior adjusters, and a champion of process improvement—all while ensuring exceptional service and regulatory compliance.   At MEM Insurance, we don’t just protect our customers—we empower our employees. We foster a culture of integrity, collaboration, and innovation. Our team thrives on solving challenges together, supporting one another, and making a meaningful impact in the lives of our policyholders and injured workers.     Essential Duties and Responsibilities: Claims Handling & Administration
  • Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles.
  • Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations.
  • Oversee medical case management for catastrophic injuries and lifetime care needs.
  • Review and authorize large or complex medical bills, negotiating adjustments to control costs.
Return-to-Work Management
  • Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants.
  • Ensure precision in benefit calculations for high-exposure claims, addressing tax and compliance risks.
  • Strategically deploy investigative efforts aligned with broader claims strategy.
Claims Investigation & Loss Prevention
  • Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.
  • Conduct subrogation analysis and negotiate with third-party insurers or attorneys for maximum recovery.
Settlements & Negotiation
  • Partner with legal teams to negotiate complex settlements and manage litigation processes.
  • Oversee Medicare compliance initiatives, including Medicare Set-Asides and CMS engagement.
  • Identify opportunities for structured settlements and lead negotiations.
Reporting
  • Produce strategic reports on high-profile claims to guide management decisions.
  • Maintain system data integrity and prepare claims for Corporate Plan of Action meetings.
Collaboration
  • Lead cross-departmental efforts to improve claims handling and risk management.
  • Resolve escalated customer service issues and support high-value accounts.
  • Participate in workflow improvement initiatives and committees.
Team Leadership
  • Mentor and coach junior and intermediate adjusters.
  • Review escalated claims and provide actionable feedback.
  • Support workforce development and succession planning.
  Qualifications:
  • Bachelor’s degree in business or related field preferred, or equivalent industry experience.
  • 7–10 years of claims handling experience, with high exposure to Workers’ Compensation.
  • Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain.
  • Texas All-Lines license preferred.
  • Valid driver’s license required.
  Company Culture and Values At MEM Insurance, we are committed to our vision, mission, and values. We foster a culture of collaboration, integrity, and innovation. Our team is passionate about delivering exceptional service to our customers while supporting each other’s growth and success. We believe in accountability, continuous learning, and creating an environment where employees feel valued and empowered.     Connection and Belonging MEM Insurance is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We believe that varied perspectives drive innovation and strengthen our ability to serve our customers and communities.     Total Rewards Overview
  • Health Plans: Medical, Dental, and Vision
    Includes fertility benefits, fully paid preventative care, and adult orthodontia.
  • Employer-Paid Life and Disability Benefits:
    Life Insurance (3x base salary), AD&D, Short and Long-term Disability.
  • Wellness and Recognition Program: Employer-paid incentives for employees and spouses.
  • Flexible Spending Account and Dependent Care options
  • Health Savings Account: Generous employer contribution.
  • Time Away from Work:
    Generous PTO, 11 Holidays + 4 Early Releases, 16 Hours Volunteer Time Off, 20 Days Paid Parental Leave, Marriage, Bereavement, and Jury Duty leave.
  • Employee Assistance Programs
  • 401k Retirement Plan: Employer match and profit sharing.
  • Adoption Assistance and Tuition Assistance
  Notice Regarding Use of Artificial Intelligence
MEM may use artificial intelligence (AI) tools to more efficiently facilitate and assist in decisions involving recruitment, hiring, promotion, renewal of employment, selection for training or apprenticeship, discharge, discipline, tenure, or the terms, privileges, or conditions of employment. Any such use of AI tools will comply with all applicable laws.
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About Mem

Sourced by ZipRecruiter

Industry

Internet and it

Company size

1 - 10 Employees

Headquarters location

Los Altos Hills, CA, US

Year founded

2019

Social media

Twitter

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