Responsibilities

As the Head of Claims, the individual will lead and oversee all core functions related to health insurance claims, including processing, auditing, appeals, training, and network/vendor coordination. They will supervise and mentor a team of claim processors, adjusters, auditors, and appeal coordinators, develop and refine SOPs and operational workflows, conduct performance evaluations, and foster a positive work environment. The role also involves overseeing the processing of claims and appeals, reviewing and auditing high dollar claims, developing a claims auditing program, monitoring claim trends, and collaborating with other departments to enhance operational efficiency. Additionally, the Head of Claims will play a key role in strategic planning, team expansion, and addressing customer complaints.