Expert: Senior claims adjuster · Course: Fraud detection · Suggested length: 60 minutes
The goal of this conversation is the judgment an experienced adjuster applies before the process ever kicks in, the feel for a claim that doesn't add up. Open easy, then move from documented steps toward the calls they make on instinct. Record it if they'll let you; the exact phrasing they use is often the teachable part.
Warm-up & context
- Walk me through a normal day. Where do claims come from, and how many cross your desk?
- When a new claim lands, what are the first few things you look at, in order?
- How did you learn to spot fraud? What changed between your first year and now?
Decision points
- Walk me through how you decide a claim is worth a second look. What tips you off?
- When you're on the fence, what's the deciding factor that pushes you one way or the other?
- At what point do you escalate to the special investigations team, and what has to be true first?
- Take the last claim you flagged. Talk me through your thinking, from the first read to the decision.
Edge cases & exceptions
- When does the usual rule of thumb break down? Tell me about a claim that looked fraudulent but wasn't.
- What's a legitimate claim that everyone new to this job gets wrong?
- Which situations don't fit any of the standard categories, and how do you handle them?
War stories
- Tell me about the most memorable fraud you ever caught. What gave it away?
- Is there one that got past you? What would you notice now that you missed then?
- What's the case you tell every new adjuster about, and why that one?
Common novice mistakes
- What do people in their first year consistently get wrong?
- Where do newer adjusters either over-flag honest claims or wave through obvious ones?
- What's a habit you had to unlearn to get good at this?
Red flags & heuristics
- If you had to name the five signals that most often mean something's off, what are they?
- Which single red flag carries the most weight for you, and which one is overrated?
- What's a combination that's harmless on its own but worth attention when it shows up together?
Use the probe column below when an answer sounds complete but stays general. Most of the teachable detail is one "can you give me an example?" past the first response.
| Topic | What to probe for |
|---|
| First read of a claim | The specific fields they check and the order, not "I review the file" |
| Gut feeling | What the feeling is actually reading, translated into observable signals |
| Escalation threshold | The concrete trigger, not the policy wording, and who they call |
| Edge cases | A real example where the standard rule gave the wrong answer |
| Novice mistakes | The tell that separates a first-year read from a seasoned one |
| Red-flag weighting | Which signals they trust, which they discount, and why |
Two tips for the room. When you hear "it depends," that's the door, not the wall: follow with "depends on what?" and "give me a case where it went the other way." And when they describe a decision as obvious, ask what a smart new hire would have done instead. The gap between those two answers is the course.
