Director, Claims Appeals

Combined Insurance, a Chubb Company, is seeking a Director, Claims Appeals for operations to join our fast-paced, high energy, growing company. We are proud of our tradition of success in the insurance industry of over 100 years. Come join our team of hard-working, talented professionals!

JOB SUMMARY

The Director, Claims Appeals is responsible for leading and managing the claims appeals department, ensuring efficient and effective processing of appeals related to claims, and confirming compliance with regulatory standards, including the Employee Retirement Income Security Act (ERISA) of 1974. This role involves strategic planning, team leadership, and collaboration with other departments, such as Claims, Legal, and Compliance to optimize the appeals process and improve outcomes. The director will guide the development and effectiveness of the team by advocating a climate of collaboration, ownership, and accountability, and work to maintain a level of excellence in the overall performance of the team.

RESPONSIBILITIES

• Serve as chief liaison for Claims Appeals activities.
• Develop and implement strategic plans to improve the efficiency and effectiveness of the claims appeals process.
• Lead, mentor, and manage a team of claims appeals specialists, providing guidance and support to achieve departmental goals.
• Oversee the review and analysis of claims, ensuring accurate and timely processing of appeals.
• Review and approve claims appeals decisions.
• Establish and maintain relationships with Claims, Legal, healthcare providers, and other stakeholders to facilitate the resolution of claims disputes.
• Monitor industry trends and regulatory changes to ensure compliance and adapt strategies accordingly.
• Analyze data and metrics to identify areas for improvement and implement process enhancements.
• Create and maintain accurate and comprehensive tracking around appeals volume and handling status.
• Engage team via coaching and mentoring to maintain culture of continuous improvement.
• Address complex claim issues and develop cross-functional solutions, partnering with stakeholders when needed.
• Build a knowledgeable, empowered, and self-driven team to inspire confidence inside and outside the department.
• Sets team goals and objectives, monitors performance, and develops and maintains a team focused on excellence.
• Ensure efficient allocation of resources and adherence to budget.
• Foster a culture of continuous improvement and professional development within the team.
• Provide input and make decisions on policies, systems, methods, and procedures for the effective management and control of the Claims Appeals functions.
• Maintain current knowledge of client needs, products, and insurance industry.
• Ensure incorporation of Compliance’s interpretation of regulations and laws into Claims processes in a user-friendly way.
• Perform other duties as assigned.

COMPETENCIES

• Problem Solving: Takes an organized and logical approach to thinking through problems and complex issues.  Simplifies complexity by breaking down issues into manageable parts. Looks beyond the obvious to get at root causes. Develops insight into problems, issues and situation.    

• Continuous Learning: Demonstrates a desire and capacity to expand expertise, develop new skills and grow professionally.  Seeks and takes ownership of opportunities to learn, acquire new knowledge and deepen technical expertise. Takes advantage of formal and informal developmental opportunities. Takes on challenging work assignments that lead to professional growth  

• Initiative: Willingly does more than is required or expected in the job.  Meets objectives on time with minimal supervision.  Eager and willing to go the extra mile in terms of time and effort. Is self-motivated and seizes opportunities to make a difference. 

• Adaptability: Ability to re-direct personal efforts in response to changing circumstances. Is receptive to new ideas and new ways of doing things. Effectively prioritizes according to competing demands and shifting objectives. Can navigate through uncertainty and knows when to change course  

• Results Orientation: Effectively executes on plans, drives for results and takes accountability for outcomes. Perseveres and does not give up easily in