Course Description

This course covers advanced methodologies for claims administration, investigation, and fraud identification within the financial sector. It is designed for insurance adjusters, claims managers, and risk analysts who need to improve payout accuracy and prevent financial loss. Participants gain practical skills in recognizing red flags, conducting structured investigations, and applying fraud analytics.

Course Objectives

  • Identify behavioral and documentary indicators of insurance fraud
  • Apply investigative interviewing techniques to gather accurate claims evidence
  • Analyze complex claims data to detect patterns of systemic abuse
  • Develop standardized protocols for escalating suspicious claims
  • Implement effective mitigation strategies to reduce fraudulent payouts

Who Should Attend?

Claims adjusters, fraud investigators, risk managers, and financial compliance officers in banking and insurance.

Course Agenda

Day 1 – Foundations of Claims Management and Red Flag Identification

  • Review of standard claims lifecycles and adjudication workflows
  • Legal and regulatory frameworks governing insurance claims
  • Categorization of common first-party and third-party fraud schemes
  • Identifying behavioral and documentary red flags during intake
  • Hands-on: Review a sample portfolio of incoming claims to flag anomalies and categorize risk levels.

Day 2 – Advanced Investigation and Data Analytics

  • Conducting structured investigative interviews and statements
  • Utilizing data analytics tools to cross-reference claimant histories
  • Investigating staged accidents, inflated losses, and medical padding
  • Collaborating with law enforcement and external legal counsel
  • Hands-on: Analyze a complex multi-party liability case study using claims database outputs to uncover collusion.

Day 3 – Fraud Prevention Strategy, Wrap-Up, and Action Planning

  • Designing internal controls to prevent fraudulent claim approvals​
  • Measuring fraud detection KPIs and recovery rates
  • Open Q&A and troubleshooting specific organizational challenges
  • Creating individual action plans for workplace implementation
  • Hands-on: Draft an updated anti-fraud standard operating procedure and present the implementation strategy.

Assessment Methodology

All courses conducted by EdTech will begin with a Pre-evaluation and end with a Post-evaluation. The instructor will evaluate the knowledge and skills of the participants according to the feedback given by participants. This will help to recognize the benefits and the level of knowledge gained by participants through the course.

Training Methodology

Facilitated by a highly qualified specialist, who has extensive knowledge and experience; this program will be conducted using extensively interactive methods, encouraging participants to share their own experiences and apply the program material to real-life work situations in order to stimulate group discussions and improve the efficiency of the subject coverage.

Percentages of the total course hour classification are:

  • ​40% Theoretical lectures, Concepts and approach
  • 20% Motivation to develop individual skill and Techniques
  • 20% Case Studies and Practical Exercises
  • 20% Topic General Discussions and interaction

Course Manual

Participants will be provided with comprehensive presentation material as reference manual. This presentation material is a compilation of core valuable information, references, presentation methods and inspiring reading which will be used as a part of the material guide.

Course Certificate

At the completion of the course, all participants who successfully accomplished the required contact hours will receive an EdTech Training Participation Certificate as a testimony to their commitment to professional development and further education.

Why Edtech ?

  • Industry Experienced; Internationally Qualified Trainers
  • Hands-on Practical Sessions & Assignments
  • Intensive Study materials
  • Flexible Schedules
  • Realistic training methodology
  • High-Quality Training in Affordable Course Fees
  • Achievement Certificate, as approved by the Ministry of Education (Abu Dhabi Center for Technical and Vocational Education Training - ACTVET), HABC, AWS, IAOSHE, SHRM, etc.