<p>The SIU team is currently seeking a Major Case Specialist. This is a full-time, exempt position with a remote or hybrid work schedule seated in one of our Claims offices. Travel may be required.</p> <p>POSITION OVERVIEW:</p> <p>The SIU Specialist is responsible for leading and executing investigations into suspected fraud specific to major case investigations with potential responsibilities in medical and/or underwriting investigations. This role ensures compliance with regulatory standards, supports litigation efforts, and collaborates with internal and external stakeholders to mitigate risk and uphold ethical claims practices.</p> <p>IN THIS ROLE, YOU WILL:</p> <ul> <li> <p>Work closely with Field Claims teams, policyholders, defense counsel, and major case claims management. Maintain strong partnerships with NICB and law enforcement agencies to support investigative efforts.</p> </li><li> <p>Conduct detailed reviews of insurance policies to assess risk during claim investigations. Analyze discovery responses, medical records, and billing to evaluate injury claims in collaboration with SIU medical specialists.</p> </li><li> <p>Lead and supervise fraud investigations across all LOBs, ensuring high-quality outcomes and adherence to performance standards. Provide ongoing guidance and evaluation to investigative staff.</p> </li><li> <p>Conduct preliminary investigations using internet and social media platforms to support claim assessments.</p> </li><li> <p>Recognized for strong critical thinking skills, the ability to overcome obstacles, and effectively prioritize and manage multiple projects. Skilled in goal setting and workflow organization to achieve optimal results.</p> </li><li> <p>Serve as a key liaison between SIU and other departments, facilitating communication and coordination on shared initiatives.</p> </li><li> <p>Recommend and implement procedural enhancements under SIU leadership. Ensure compliance with regulatory requirements and proper reporting to state and fraud prevention agencies.</p> </li><li> <p>Deliver ongoing education on SIU initiatives to internal departments. Engage in continuous professional development focused on liability investigations, injury evaluation, settlement negotiation, and litigation management.</p> </li><li> <p>Manage assignments generated from SIU systems and models, including oversight of NICB alerts, ForeWarns, AMDs, and Strategic Alerts. Focus on increasing penetration in underrepresented states such as CA, MA, NY, NJ, PA, GA, and IL to drive diversification.</p> </li><li> <p>Direct underwriting fraud investigations across Personal and Commercial Lines.</p> </li><li> <p>Identify and investigate rate evasion, premium avoidance, and misrepresentation.</p> </li><li> <p>Coordinate with underwriting, claims, and agency partners to ensure alignment and compliance.</p> </li><li> <p>Utilize predictive modeling and fraud detection tools (e.g., Accurint, ISO, DMV records).</p> </li><li> <p>Deliver training on underwriting fraud trends and SIU protocols.</p> </li><li> <p>Supervise investigations into medical fraud across Workers' Compensation, PIP, ABI, and CGL.</p> </li><li> <p>Analyze complex medical claims using tools such as MedSentry, IES, and internal watchlists.</p> </li><li> <p>Oversee field investigations and vendor performance.</p> </li><li> <p>Collaborate with Medicare/Medicaid task forces and regulatory bodies.</p> </li><li> <p>Provide training on medical fraud detection and compliance.</p> </li></ul> <p>WHAT YOU NEED TO APPLY:</p> <ul> <li> <p>Experience: 10+ years in SIU, fraud detection, or complex claims management.</p> </li><li> <p>Education: Bachelor's degree required; advanced degree or clinical background preferred for medical focus include RN, LPN, OT, PT, or CPC.</p> </li><li> <p>Certifications: Preferred designations include CPCU, AIC, CIFI, FCLS, CPC, CFE, AHFI.</p> </li><li> <p>Technical Proficiency: Skilled in investigative tools and Microsoft Office Suite (Excel, Word, Power BI, Power Apps).</p> </li><li> <p>Proven experience managing complex claims across Casualty, Large Property, and Specialty Niche lines, including Commercial Property, Inland Marine, Excess/Umbrella, Excess Casualty Mid-Market, Management Liability, and Surety.</p> </li><li> <p>Demonstrated success in investigating complex bodily injury and litigation claims, including organized fraudulent activity. Skilled in project management within Special Investigations Unit (SIU) operations.</p> </li><li> <p>Proficient in resolving complex litigated files nationwide through collaboration with claims leadership, NICB, and law enforcement at all levels. Responsible for the selection, oversight, and coordination of defense counsel, and the development of mediation and trial strategies with a focus on fraud, waste, and abuse.</p> </li><li> <p>Willing and able to travel nationwide to attend depositions, mediations, and trials. Actively involved in setting loss and expense reserves, managing litigation and vendor budgets, and ensuring a superior customer experience.</p> </li><li> <p>Investigative Expertise: Strong in interviewing, evidence collection, and litigation support.</p> </li><li> <p>Communication: Excellent verbal and written communication; adept at cross-functional collaboration.</p> </li><li> <p>Leadership: Proven ability to mentor teams, manage projects, and drive performance.</p> </li><li> <p>Analytical Thinking: Strong problem-solving, data analysis, and strategic planning capabilities.</p> </li><li> <p>Compliance: Deep understanding of regulatory reporting and fraud prevention standards.</p> </li><li> <p>Customer Focus: Committed to ethical practices and delivering exceptional service.</p> </li><li> <p>Proficient in operating a personal computer and standard office equipment to complete daily responsibilities efficiently.</p> </li><li> <p>Ability to sit or stand for extended periods, depending on task requirements.</p> </li><li> <p>Flexibility to work on-site as needed, based on business priorities.</p> </li><li> <p>Willingness and ability to travel for meetings, training sessions, or operational support, as required.</p> </li><li> <p>Availability to work outside of standard business hours-including evenings or weekends-based on workload or project demands.</p> </li><li> <p>Ability to perform effectively in a fast-paced, dynamic, and occasionally high-pressure environment.</p> </li><li> <p>Comfortable working in environments with varying levels of ambient noise.</p> </li></ul> <p>This job posting provides cursory examples of some of the job duties associated with this position. The examples provided are not complete, and the position may entail other essential and job-related functions and responsibilities that employees will be required to perform.</p>