Job Description

Job Title: Director Claims Counsel

Department: Claims Management

Work Location: Remote

Reports To: VP of Customer Experience

Classification: Exempt

A day in the life of MetLife Legal Plans Director Claims Counsel:

The Director Claims Counsel is a senior leader within MetLife Legal Plans responsible for overseeing the review approval and resolution of claims billing inquiries out-of-network claims matters and appeals. This role ensures claims are handled accurately consistently and in compliance with departmental service level agreements (SLAs) regulatory requirements and company standards.

In addition to serving as the legal authority for complex and highvalue claims the Director Claims Counsel leads and develops a team of 34 professionals and partners closely with internal stakeholders to drive quality outcomes operational efficiency and continuous improvement across the claims organization.

Key Responsibilities

Claims Review & Oversight

• Review adjudicate and approve complex and highvalue claims including approvals rejections and adjustments in accordance with approved fee schedules and coverage determinations
  • Primary focus on negotiated arrangements preapproved fee schedules and escalated matters
• Provide secondlevel approvals for claims reviewed by team members
• Maintain ultimate accountability for claims decisions made by direct reports
• Ensure all claims are processed and approved within established payment schedules and SLAs
• Review billing inquiries (kicks) to determine appropriate payment actions and whether additional documentation is required from attorneys
• Identify billing trends issues or concerns with network providers and escalate or collaborate with Panel Management as appropriate

Out of network claims& Appeals Leadership

• Oversee the review of out-of-network claims to ensure accuracy compliance and timely payment requesting additional information from members when necessary
• Provide legal guidance to the Claims Team on matters involving legal interpretation coverage or complex reimbursement issues
• Advise and support the Claims Team in responding to member inquiries and resolving escalated out of network claims concerns
• Review and respond to out-of-network claims and coverage/claims appeals in compliance with company SLAs and regulatory requirements

Leadership & People Management

• Lead coach and develop a team of 34 individuals fostering a culture of accountability ownership empowerment and continuous learning
• Conduct regular 1:1 meetings performance reviews and development planning to support individual and team growth
• Serve as a trusted claims and legal subjectmatter expert for internal partners and senior stakeholders

Systems Process & Audit Support

• Support claims systems and application management including:
  • Participation in User Acceptance Testing (UAT)
  • Defining and documenting business and feature requirements for system enhancements
  • Identifying documenting and reporting system issues including performance trends and business impact
• Support internal and external claims audit activities ensuring documentation processes and outcomes meet audit and compliance standards

Additional Responsibilities

• Address coverage and claims appeals and escalations
• Serve as a coverage expert for MLP
• Provide training/education sessions on legal coverage and claims processing for Claims and Panel Organization
• Partner crossfunctionally to improve claims processes controls and member experience
• Perform other duties as assigned

Ideal Qualifications

• Bachelors degree from an accredited university
• Property & Casualty licensing preferred
  • Candidates without active licenses must be willing to obtain them
• J.D. from an accredited law school with 4 years of experience as a practicing attorney (preferred)
• 5 years of experience in claims administration fee reimbursement billing inquiries or related work
• Demonstrated leadership experience with the ability to build highperforming teams and lead with clarity and accountability
• Strong expertise in claims review adjudication and approval processes
• Proven ability to analyze and interpret complex fee legal and coverage issues
• Strong communication skills with the ability to engage effectively with attorneys members and internal stakeholders on sensitive matters
• High degree of professionalism discretion and confidentiality
• Strong organizational and timemanagement skills with the ability to manage competing priorities in a highvolume environment
• Proficiency with Microsoft Office tools including Teams Excel Outlook and PowerPoint
• Positive adaptable and solutionsoriented leadership style

What Will Make You Stand Out

• Broad legal experience across general practice and litigation matters
• Prior experience leading or managing a team in a claims or legal environment
• 7 years of experience with claims fee reimbursements and billing inquiries
• Active licensure as a Claims Adjuster

Travel

This position requires up to 5% travel.

Note: This job description in no way states or implies that these are the only duties to be performed by the associate in this position. Associates will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully the incumbent will possess the skills aptitude and ability to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge skills or abilities. This document does not create an employment contract implied or otherwise other than an at-will relationship.

MetLife Legal Plans is an Equal Opportunity Employer. All employment decisions are made without regards to race color national origin religion creed sex (including pregnancy childbirth or related medical conditions) sexual orientation gender identity or expression age disability marital or domestic/civil partnership status genetic information citizenship status (although applicants and employees must be legally authorized to work in the United States) uniformed service member or veteran status or any other characteristic protected by applicable federal state or local law (protected characteristics).

If you need an accommodation due to a disability please email us at . This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

Required Experience:

Director

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