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Key Responsibilities and Required Skills for Examiner

💰 $ - $

🎯 Role Definition

The Examiner is an investigative and evaluative professional responsible for planning and conducting thorough examinations of records, transactions, processes, claims, or applications to verify compliance with applicable laws, regulations, policy, and organizational standards. Examiners synthesize complex information, identify risk and control weaknesses, produce clear findings and recommendations, and work with business units, legal, and enforcement teams to ensure corrective action and risk mitigation. This role requires strong analytical capability, detailed documentation and report writing, sound judgment, and the ability to manage a caseload while maintaining confidentiality and regulatory objectivity.

Search keywords: Examiner, compliance examiner, claims examiner, regulatory examiner, audit examiner, case management, risk assessment, investigative reporting, policy enforcement, quality assurance.

📈 Career Progression

Typical Career Path

Entry Point From:

  • Junior Analyst, Compliance or Audit Assistant transitioning into examination work after exposure to documentation, controls, and casework.
  • Claims Processor or Eligibility Specialist with hands-on experience in application review and adjudication.
  • Investigator or Quality Assurance Specialist moving into formal examination and reporting duties.

Advancement To:

  • Senior Examiner / Lead Examiner responsible for complex examinations and mentoring.
  • Supervising Examiner or Team Lead overseeing examiner teams and workflow.
  • Compliance Manager, Audit Manager, or Regulatory Enforcement Manager responsible for program strategy and escalations.

Lateral Moves:

  • Quality Assurance Analyst focusing on process improvements and metrics.
  • Regulatory Affairs Specialist translating findings into policy or rulemaking.

Core Responsibilities

Primary Functions

  • Plan and execute risk-based examinations by scoping objectives, identifying applicable laws, regulations, policies and standards, and developing an examination work plan with milestones and resource needs.
  • Review, interpret and analyze complex documentation, including financial statements, application files, claims histories, contracts, system logs and correspondence, to validate accuracy, completeness and compliance with governing rules.
  • Conduct interviews with internal staff, regulated entities, claimants, witnesses, and third parties to gather evidence, corroborate facts, and clarify anomalies identified during document review.
  • Perform on-site and remote inspections and walkthroughs of processes, systems and controls to observe operations firsthand and verify that documented procedures are implemented consistently.
  • Execute data analytics and exception testing using spreadsheets, databases, and specialized examination tools to identify trends, outliers, suspicious patterns, and systemic weaknesses that warrant further investigation.
  • Evaluate internal controls, operational processes and risk management practices; identify control gaps and provide prioritized recommendations to remediate deficiencies and reduce regulatory or operational risk.
  • Prepare timely, accurate and well-substantiated examination reports, memoranda and deficiency letters that document findings, impacts, recommended corrective actions and timelines for remediation.
  • Draft formal orders, deficiency notices, or adverse findings in accordance with agency or organizational policy, ensuring that legal and procedural requirements for due process are met.
  • Maintain and update case files and records in the case management system, ensuring all evidence, interview notes, work papers and communications are organized, secure and audit-ready.
  • Monitor corrective action plans and follow-up reviews to verify that agreed remedies have been implemented effectively and within established deadlines.
  • Escalate significant compliance violations, potential fraud, or high-risk issues promptly to supervisors, legal counsel or enforcement teams and assist with referral and prosecution efforts when required.
  • Coordinate cross-functional reviews with legal, audit, IT, actuarial, product, and operations teams to assess multifaceted issues and develop integrated remediation plans.
  • Make sound, independent determinations on eligibility, claim validity, regulatory compliance, or corrective measures based on objective analysis and documented evidence.
  • Serve as subject matter expert for assigned programs or regulatory areas by staying current on statutes, guidance, case law, and industry best practices, and by advising stakeholders on interpretation and application.
  • Provide technical support and expert testimony for administrative hearings, appeal proceedings or court cases, preparing exhibits and presenting factual findings clearly and persuasively.
  • Identify and recommend process improvements, policy changes, or automation opportunities to increase examination effectiveness, reduce cycle time, and strengthen internal controls.
  • Mentor and train junior examiners, new staff, or cross-functional partners on examination methodologies, documentation standards, investigative techniques and technology tools.
  • Ensure strict confidentiality and chain-of-custody procedures for sensitive information and evidence, complying with privacy laws, records retention schedules and internal security protocols.
  • Manage a complex caseload, prioritizing work, meeting statutory deadlines, and producing consistently high-quality deliverables while balancing competing demands.
  • Track and analyze examination metrics, trends and performance indicators to identify systemic risks, recurring issues, and opportunities for enterprise-level mitigation strategies.
  • Participate in the development and revision of examination manuals, standard operating procedures and quality assurance protocols to maintain consistency and regulatory alignment across units.
  • Support investigations into potential fraud, waste or abuse by compiling evidence packages, performing cross-referencing analysis and liaising with fraud investigators and law enforcement.
  • Perform legal and regulatory research to interpret statutes, rules, guidance and precedent and incorporate results into examination conclusions and written rationale.
  • Facilitate stakeholder communication and outreach, including pre-examination notifications, exit conferences, and status updates, while maintaining professional impartiality.

Secondary Functions

  • Support ad-hoc data requests and exploratory data analysis.
  • Contribute to the organization's data strategy and roadmap.
  • Collaborate with business units to translate data needs into engineering requirements.
  • Participate in sprint planning and agile ceremonies within the data engineering team.

Required Skills & Competencies

Hard Skills (Technical)

  • Deep knowledge of applicable regulatory frameworks, statutes, and policy guidance relevant to the program area (e.g., insurance, banking, social benefits, patents, licensing).
  • Case management and workflow system proficiency (e.g., CMS, SharePoint, Salesforce Service Cloud, or agency-specific case systems).
  • Advanced document review and evidence management skills, including maintaining chain-of-custody and audit-ready work papers.
  • Financial statement analysis and accounting knowledge for assessing transactions, reconciliations and control effectiveness.
  • Data analysis and interrogation skills using Excel (pivot tables, VLOOKUP/XLOOKUP), SQL, Python, R, or specialized analytics platforms to identify anomalies and trends.
  • Experience drafting formal reports, deficiency notices, legal findings and administrative orders with clear organization and legal sufficiency.
  • Familiarity with investigative techniques, interview best practices, and evidence preservation.
  • Risk assessment and control evaluation methodologies including internal control frameworks (e.g., COSO) and risk-based planning.
  • Legal and regulatory research tools and techniques (e.g., Westlaw, LexisNexis, government code repositories).
  • Knowledge of fraud detection indicators, referral procedures, and collaboration with investigative units.
  • Proficiency with productivity tools: MS Office suite (Word, Excel, PowerPoint), PDF redaction tools, and document comparison utilities.
  • Experience presenting findings to management, enforcement teams, or external stakeholders using data visualizations and clear executive summaries.

Soft Skills

  • Exceptional analytical thinking and ability to synthesize large volumes of complex information into concise findings and actionable recommendations.
  • Strong written communication and report-writing skills with attention to legal adequacy and clarity for non-technical stakeholders.
  • Excellent verbal communication and interpersonal skills for conducting interviews, delivering exit conferences, and influencing remediation.
  • High ethical standards, integrity and demonstrated ability to handle confidential, sensitive information.
  • Critical thinking and sound judgment in weighing evidence and making impartial determinations.
  • Detail orientation and meticulous organizational skills for maintaining accurate, defensible case files.
  • Time management and prioritization skills to manage caseloads and meet statutory or SLA deadlines.
  • Resilience and adaptability to work in fast-paced, high-pressure environments with shifting priorities.
  • Collaborative mindset and ability to work cross-functionally with legal, IT, operations, policy, and audit teams.
  • Coaching and mentoring ability to develop junior staff and promote consistent examination quality.

Education & Experience

Educational Background

Minimum Education:

  • Bachelor's degree in Accounting, Finance, Criminal Justice, Public Administration, Business, Law, Information Systems, or a related field; or equivalent combination of education and relevant professional experience.

Preferred Education:

  • Bachelor’s or Master’s degree in Law (JD), Accounting (CPA), Finance (CFA), Public Administration, or closely related discipline.
  • Professional certifications such as Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA), CPA, or similar certifications are highly desirable.

Relevant Fields of Study:

  • Accounting
  • Finance
  • Law / Legal Studies
  • Public Administration / Policy
  • Criminal Justice / Investigations
  • Information Systems / Data Analytics

Experience Requirements

Typical Experience Range:

  • 2 to 7 years of progressively responsible experience in examinations, compliance, claims adjudication, auditing, investigations, or regulatory enforcement.

Preferred:

  • 3+ years of direct examination or investigative experience within the relevant industry (e.g., financial services, insurance, healthcare, benefits administration, government regulatory agencies).
  • Demonstrated experience producing formal reports, legal findings, or enforcement recommendations and managing end-to-end examination cases.
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