VP, Medical Claims & Reinsurance Operations

Davies North America

Kansas

Hybrid

USD 180,000 - 230,000

Full time

7 days ago

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Job summary

Davies North America seeks an Assistant Vice President to lead claims staff and oversee medical excess and reinsurance claims operations, as well as payment integrity activities supporting reinsurers, issuing carriers, MGUs, and risk-bearing entities.

The role requires a seasoned leader with 10+ years in medical claims management, strong governance, and client-facing abilities to drive efficiency and client satisfaction in a complex reinsurance environment.

Qualifications

Seasoned experience (10 years +) of progressively increasing responsibility in medical claims management and related areas.
Leadership experience managing claims professionals, workflows, quality, and client deliverables.
Strong knowledge of self-insured plans, managed care concepts and risk sharing arrangements.
Working knowledge of CMS regulations, Medicare and Medicaid programs and fee schedules.
Excellent leadership, client service, communication, analytical, and problem-solving skills with strong attention to detail.
Proficiency in Microsoft Word and Excel and the ability to manage multiple priorities independently in a fast-paced environment.

Responsibilities

Lead claims staff, including Claims Directors, Claims Examiners, and Claims Assistants, with coaching, performance management, workload oversight, and development.
Oversee assigned client accounts and serve as a senior contact for clients, intermediaries, and internal colleagues.
Review complex or escalated claims and ensure supporting documentation is obtained and maintained.
Support client retention, account transitions, and business development activities as requested.
Oversee complex Medical Excess of Loss, Provider Excess of Loss, HMO Reinsurance, and Employer Stop Loss specific excess claims and reinsurance matters, including payment integrity reviews and coordination of benefits.
Review and interpret insurance policies, reinsurance agreements, provider contracts, risk-sharing arrangements, and claim data to determine coverage and reimbursement.
Apply knowledge of medical and pharmacy claims, reimbursement methodologies, medical coding, CMS regulations, and Medicare/Medicaid programs.
Use internal and external claims systems to manage claim data and workflows.
Monitor quality standards, maintain review records, and address operational or service risks.
Prepare or review client reports, savings reports, invoices, and other recurring deliverables.
Improve claims procedures, controls, reporting practices, and workflow efficiency.
Collaborate with leadership on staffing, operational planning, and special projects; travel occasionally for audits, projects, or client meetings.