Role Description To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements. Essential Functions and Responsibilities - Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. - Negotiates settlement of claims within designated authority. - Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. - Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level. - Prepares necessary state fillings within statutory limits. - Manages the litigation process; ensures timely and cost effective claims resolution. - Coordinates vendor referrals for additional investigation and/or litigation management. - Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. - Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. - Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. - Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. - Ensures claim files are properly documented and claims coding is correct. - Refers cases as appropriate to supervisor and management. Additional Functions and Responsibilities - Performs other duties as assigned. - Supports the organization's quality program(s). - Travels as required. Qualifications - Education & Licensing: Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. - Experience: Five (5) years of claims management experience or equivalent combination of education and experience required. - Skills & Knowledge: - Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business. - Excellent oral and written communication, including presentation skills. - PC literate, including Microsoft Office products. - Analytical and interpretive skills. - Strong organizational skills. - Good interpersonal skills. - Excellent negotiation skills. - Ability to work in a team environment. - Ability to meet or exceed Service Expectations. Work Environment - Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines. - Physical: Computer keyboarding, travel as required. - Auditory/Visual: Hearing, vision and talking. Requirements - Credit security clearance, confirmed via a background credit check, is required for this position. Benefits - A comprehensive benefits package is offered including but not limited to: - Medical, dental, vision. - 401k and matching. - PTO. - Disability and life insurance. - Employee assistance. - Flexible spending or health savings account. - Other additional voluntary benefits.

Role Description Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world’s best brands? Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. - Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world’s most respected organizations. - Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. - Leverage Sedgwick’s broad, global network of experts to both learn from and to share your insights. - Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. - Enjoy flexibility and autonomy in your daily work, your location, and your career path. - Access diverse and comprehensive benefits to take care of your mental, physical, financial, and professional needs. Qualifications - Bachelor's degree from an accredited college or university preferred. - Professional certification as applicable to line of business preferred. - Four (4) years of claims management experience or equivalent combination of education and experience required. Requirements - To analyze mid- and higher-level workers compensation claims to determine benefits due. - To ensure ongoing adjudication of claims within company standards and industry best practices. - To identify subrogation of claims and negotiate settlements. Benefits - Flexible work schedule. - Referral incentive program. - Opportunity to work in an agile environment. - Career development and promotional growth opportunities. - A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. Work Environment - Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines. - Physical: Computer keyboarding, travel as required. - Auditory/Visual: Hearing, vision and talking.

• Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets and Macess Systems. • Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. • Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. • Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. • Meets or exceeds department quality and work management standards for claims adjudication. • Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. • Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. • Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. • Keeps abreast of all benefit changes. • Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Role Description Zurich is seeking an experienced Claims Fraud Investigator to join its Claims Fraud and Investigation team. The ideal candidate for this role will have the opportunity to work fully remote from one of the following states: Arizona, Nevada, California, or Utah. However, we are also open to candidates who prefer to work fully remote across the West Coast, and will consider strong candidates throughout the U.S. as well. Under general direction and within defined authority limits, this role is responsible for conducting insurance fraud investigations involving complex schemes, multi-claim patterns, organized activity, and non-medical major case work. The investigator will perform field activities, coordinate vendor resources, conduct interviews, gather evidence, and deliver clear, objective, and fact-based investigative reports. This role may also support California and travel insurance related investigations as needed. Field travel may be required to conduct interviews, scene examinations, statement collection, evidence gathering, examinations under oath, and support legal proceedings. Primary Responsibilities: - Conduct investigations into suspected insurance fraud within assigned territories or Lines of Business, including complex, layered, or organized schemes. - Evaluate all aspects of referred claims, including loss circumstances, backgrounds of involved parties, documentation validation, and underwriting considerations. - Perform database research, open source intelligence reviews, social media assessments, and link analysis to identify inconsistencies or coordinated fraud indicators. - Assign and oversee vendor activities such as surveillance, scene investigations, and specialized investigative tasks; review deliverables and ensure proper documentation. - Conduct recorded interviews, site visits, canvasses, and other investigative steps to verify material facts and identify fraud indicators. - Maintain highly organized case files and documentation that accurately reflect investigative actions and findings. - Analyze evidence to determine potential misrepresentation, fraud, or network linked activity involving multiple claims. - Prepare clear, comprehensive investigative reports with objective findings and recommendations for claims teams and management. - Communicate critical investigative developments promptly and collaborate closely with claims partners throughout the investigative process. - Identify cases that warrant escalation due to suspected organized fraud rings, staged events, or potential law enforcement involvement. - Ensure all investigative activity complies with SIU regulatory requirements, privacy laws, and Zurich governance standards. - Travel as necessary to conduct interviews, inspections, and field investigations. Qualifications - Bachelor’s Degree and 4 or more years of experience in Technical Claims Investigations, Law Enforcement, or Insurance Special Investigations - OR Zurich Certified Insurance Apprentice (Associate Degree) and 4 or more years of relevant experience - OR High School Diploma or Equivalent and 6 or more years of experience in Technical Claims Investigations, Law Enforcement, or Insurance Special Investigations - Knowledge of claims processes and relevant fraud related regulations - Proficiency in Microsoft Office Requirements - Prior law enforcement investigation experience - 5 or more years investigating insurance fraud - Special Investigation Unit (SIU) experience preferred - Experience investigating commercial claims - Experience with both single non-complex investigations and complex investigations, including multi-claim linkages, contractor or vendor fraud, or organized fraud networks Benefits - Your pay at Zurich is based on your role, location, skills, and experience. - We follow local laws to ensure fair compensation. - You may also be eligible for bonuses and merit increases. - The proposed Salary range for this position is $65,900.00 - $107,900.00, with short-term incentive bonus eligibility set at 10%. - We offer competitive pay and comprehensive benefits for employees and their families.