INSURANCE FRAUD DETECTION WORKFLOW

Created by ChecklistGuro (https://checklistguro.com)

[ ] Fetch New Claim Submission: Retrieve the details of the recently submitted insurance claim from the Claims Data Model.
[ ] Fetch Policyholder History: Retrieve all previous claim entries associated with the specific policyholder ID.
[ ] Fetch Blacklisted Entities: Retrieve data from the Fraudster Watchlist model to check for matching names or bank accounts.
[ ] Calculate Total Claim Value (Lifetime): Sum the value of all historical claims for this policyholder to detect patterns of frequent small-value claims.
[ ] Calculate Frequency of Claims: Count the number of claim entries submitted by the user within the last 12 months.
[ ] Calculate Risk Score: Apply a formula combining claim amount, frequency, and blacklist matches to generate a numeric fraud probability score.
[ ] Assign to Fraud Investigator: Create a high-priority task for the Fraud Investigation Team if the Risk Score exceeds the threshold.
[ ] Assign to Standard Review: Create a routine task for a Claims Adjuster if the Risk Score is within normal parameters.
[ ] Update Claim Status: Update the status of the initial claim entry to 'Under Investigation' or 'Flagged'.
[ ] Create Incident Report: Create a new entry in the Fraud Investigation Log detailing the findings of the investigation.
[ ] Notify Investigator: Send an email to the assigned investigator with a link to the flagged claim and the calculated risk score.
[ ] Alert Policyholder: Send a generic automated email to the policyholder informing them that additional documentation is required for verification.
[ ] Urgent Alert SMS: Send an SMS alert to the Fraud Manager for extreme-risk cases (Risk Score > 90).
[ ] Update Blacklist: If fraud is confirmed, update the Blacklist Data Model to include the fraudulent entity's details.
[ ] Generate Monthly Fraud Trend Report: Create a summary report aggregating all flagged and confirmed fraud entries for the monthly management review.
[ ] Remove Erroneous Flags: Delete a flagged entry from the investigation queue if the investigation proves the claim was legitimate.

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