Assistant Vice President, Medical Claims Operations

Davies
United States
Workplace: RemoteFull timeFunction: Executive & General ManagementExperience: 10+ yearsSkills: ["Leadership","Client service","Communication","Analytical","Problem-solving"]

Lead and manage medical claims operations, overseeing claims staff, training, performance management, and workflow priorities. Serve as a senior point of contact for client accounts, reviewing complex escalated claims and ensuring documentation, status communications, and issue resolution. Provide technical oversight for medical excess of loss, reinsurance, and payment integrity activities, applying CMS/Medicare/Medicaid and claims processing expertise while improving quality and operational procedures.

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Davies
Davies
13 hours ago

Assistant Vice President, Medical Claims Operations

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Last checked: 13 hours agoStatus: Live

Job Summary

Lead and manage medical claims operations, overseeing claims staff, training, performance management, and workflow priorities. Serve as a senior point of contact for client accounts, reviewing complex escalated claims and ensuring documentation, status communications, and issue resolution. Provide technical oversight for medical excess of loss, reinsurance, and payment integrity activities, applying CMS/Medicare/Medicaid and claims processing expertise while improving quality and operational procedures.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Executive & General Management
Seniority: Director level

Key Responsibilities

  • •Manage and coach claims staff, including performance management, workload oversight, and development.
  • •Assign work and monitor priorities and productivity to ensure accurate, on-schedule completion of assignments.
  • •Oversee complex medical excess of loss, provider excess of loss, HMO reinsurance, and employer stop loss claims, including payment integrity reviews and reimbursement disputes.
  • •Review and interpret insurance and reinsurance documentation (policies, agreements, summary plan descriptions, provider contracts) to determine coverage and reimbursement.
  • •Monitor quality standards, improve claims procedures and workflow efficiency, prepare client deliverables, and support staffing/operational planning and special projects.
Travel: Low travel

Key Requirements

  • •10+ years of progressively increasing responsibility in medical claims management and managed care claims operations, including payment integrity and provider risk management for employer stop loss and/or medical excess claims.
  • •Experience leading claims professionals and managing workflows, quality, and client deliverables.
  • •Strong knowledge of self-insured plans, managed care concepts, risk-sharing arrangements, and medical and pharmacy claims and reimbursement methodologies.
  • •Working knowledge of CMS regulations, Medicare and Medicaid programs, fee schedules, medical terminology, and coding.
  • •Proficiency in Microsoft Word and Excel, with the ability to manage multiple priorities in a fast-paced environment.
Experience:10+ yearsManaged carePayment integrityHealth insuranceReinsuranceMedical claims
Skills:LeadershipClient serviceCommunicationAnalyticalProblem-solving
Tech Stack:Microsoft WordMicrosoft ExcelClaims Adjudication System

Company Brief

Davies
Davies is a specialist professional services and technology firm delivering claims, underwriting, and risk solutions to insurers, reinsurers, brokers and regulated businesses globally, with major capabilities in claims management, forensics, and digital transformation.
Industry: Consulting
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Established Company
Valuation: Unicorn (USD 1B+)
Funding: Private Equity Backed
Headquarters: City of London, United Kingdom
Founded: 1968
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Glassdoor: 3.8
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