Claim Rep Sr - SIU, Casualty - Major Case (Hybrid or Remote)

MAPFRE•Webster, MA

4d•$52,100 - $82,200•Hybrid

About The Position

We are looking for an experienced SIU Major Case Adjuster for investigation, evaluation, and resolution of complex, high-severity suspicious personal injury claims involving potential fraud, organized schemes, material misrepresentation, and/or significant financial exposure. This role primarily handles Massachusetts personal injury claims, including Bodily Injury, Personal Injury Protection (PIP), Uninsured/Underinsured Motorist (UM/UIM), and related fraud investigations, with occasional exposure to physical damage claims. The position requires expert knowledge of Massachusetts insurance laws including Code of MA Regulations (CMRs), PIP benefits, CPT coding analysis, AIS bill review systems, provider fraud investigations, and claim handling practices. This role offers the opportunity to work independently, collaborate with legal and investigative partners, and play a critical role in protecting both our customers and the organization through thoughtful, strategic claim handling.

Requirements

Bachelor's degree or equivalent combination of education and related experience.
2+ years of casualty claims handling experience, including Bodily Injury and related coverages.
Strong investigative, analytical, and negotiation skills.
Experience interpreting insurance policies, coverage provisions, and applicable statutes.
Excellent written and verbal communication skills.
Ability to manage multiple priorities in a fast-paced environment.
Ability to obtain and maintain required state adjuster licenses.

Nice To Haves

Experience handling SIU, fraud-related, or highly complex casualty claims.
Strong knowledge of Massachusetts insurance laws, regulations, coverage analysis, and claims handling practices.
Working knowledge of CPT, HCPCS, and ICD coding systems.
Experience utilizing AIS bill review systems or similar medical bill review platforms.
Ability to identify suspicious treatment patterns, billing irregularities, provider fraud indicators, and organized fraud schemes.
Litigation management experience.
Insurance coursework, professional designations, or industry certifications.
Bilingual language skills.
Experience working with attorneys, medical experts, and law enforcement agencies.

Responsibilities

Manage a diverse caseload of casualty claims, including Bodily Injury, PIP/No-Fault, Med Pay, UM/UIM, and suspected fraud-related matters.
Conduct detailed investigations through recorded statements, scene reviews, witness interviews, database research, and collaboration with field investigators.
Analyze policy coverage, liability exposures, damages, medical records, treatment plans, billing documentation and provider activity to ensure compliance with CMRs, as well as applicable statutes across multiple jurisdictions.
Evaluate medical treatment, wage loss claims, and other damages using a variety of investigative resources including the utilization of CPT, HCPCS, and ICD coding knowledge to evaluate treatment and billing practices.
Collaborate with the Massachusetts Insurance Fraud Bureau, law enforcement, defense counsel, and regulatory partners.
Actively engage in ongoing professional development by attending industry conferences, participating in virtual and in-person training programs, and completing relevant webinars and educational opportunities.
Prepare investigative reports, referrals, and prosecution packages as appropriate.
Manage litigation-related investigations and support depositions, EUOs, arbitrations, mediations, and trials.
Develop effective claim strategies that lead to timely and fair resolutions.
Negotiate settlements through phone conferences, mediations, arbitrations, and face-to-face discussions.
Maintain accurate reserves and manage claim expenses responsibly.
Partner with experts, medical professionals, and vendors to support claim evaluations and investigations.
Direct and oversee defense counsel on litigated claims.
Participate in depositions, examinations under oath, mediations, arbitrations, and trial-related activities.
Prepare responses to regulatory inquiries, consumer complaints, and Department of Insurance matters.
Ensure compliance with state regulations and company claim-handling standards.
Serve as a mentor and resource for less experienced adjusters.
Share best practices and contribute to training initiatives.
Recommend process improvements that enhance efficiency and customer experience.
Represent the organization with professionalism in all internal and external interactions.