Medical Claims Operations Director

Coralisle Group; Hamilton; Hybrid; GBP 91,000 - 136,000; Full time

Benefits offered by this job

Competitive compensation

Comprehensive benefits package

Professional growth opportunities

Job summary

Coralisle Group Ltd. is seeking a seasoned Senior Manager to lead the Claims Department across Bermuda and EC territories.

You will oversee adjudication of medical, dental, vision, life, and disability claims, ensuring accuracy, timeliness, and cost efficiency in line with policies and regulatory requirements. You will drive continuous process improvements, manage relationships with providers, vendors, and regulators, and mentor a large team to meet service standards.

Qualifications

• Minimum of 10 years’ medical claims experience, including local and international claims adjudication.
• Demonstrated experience managing high-volume medical claims operations.
• Extensive knowledge of medical, dental, vision, prescription drug, life, and disability benefits.
• Strong understanding of healthcare reimbursement methodologies, provider contracting, utilization management, and medical cost containment strategies.
• Strong knowledge and current proficiency in ICD-10, CPT, ADA, ODA coding systems and medical terminology.
• Knowledge of HIPAA and other healthcare privacy regulations is considered an asset.
• Experience participating in healthcare industry committees, Bermuda Health Council initiatives are highly desirable.
• Strong leadership, coaching, communication, analytical, organizational, decision-making, problem-solving, and strategic thinking skills.
• Ability to interpret complex medical documentation, work effectively under pressure and manage multiple priorities.
• Strong English and mathematics skills.
• Advanced proficiency in Microsoft Office applications and business systems.

Responsibilities

• Oversee the overall workflow, productivity, quality, and operational effectiveness of the Claims Department in Bermuda and EC territories.
• Monitor inventory levels, claims processing turnaround times, auditing results, and departmental performance metrics to ensure established objectives are achieved.
• Communicate daily inventory, operational risks, trends, and staffing concerns to the Director of Operations or designate.
• Ensure follow-up requests are managed effectively and in a timely manner.
• Develop, implement, and maintain claims policies, procedures, workflows, and internal controls as required.
• Monitor performance standards, goals, objectives; report achievements and addresses underperformance.
• Identify opportunities for process improvement, automation, and operational efficiencies.
• Support claims fraud detection, investigation, prevention, and recovery activities.
• Lead and participate in strategic projects, technology enhancements, and business process improvement initiatives.

Skills

Medical claims

Leadership

Claims management

Healthcare insurance

ICD-10/CPT coding

Tools

Microsoft Office

Claims adjudication software

Job description

Coralisle Group Ltd. is seeking a seasoned Senior Manager to lead the Claims Department across Bermuda and EC territories.

You will oversee adjudication of medical, dental, vision, life, and disability claims, ensuring accuracy, timeliness, and cost efficiency in line with policies and regulatory requirements. You will drive continuous process improvements, manage relationships with providers, vendors, and regulators, and mentor a large team to meet service standards.