Director, Claims Counsel (42)

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 high-value claims, the Director, Claims Counsel leads and develops a team of 3–4 professionals and partners closely with internal stakeholders to drive quality outcomes, operational efficiency, and continuous improvement across the claim's organization.

Key Responsibilities

• Claims Review & Oversight
• Review, adjudicate, and approve complex and high-value claims, including approvals, rejections, and adjustments, in accordance with approved fee schedules and coverage determinations
• Provide second-level 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 3–4 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 subject-matter 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 cross-functionally to improve claims processes, controls, and member experience
• Perform other duties as assigned

Ideal Qualifications

• Bachelor's degree from an accredited university
• Property & Casualty licensing preferred
• 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 high-performing 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 time-management skills with the ability to manage competing priorities in a high-volume environment
• Proficiency with Microsoft Office tools, including Teams, Excel, Outlook, and PowerPoint
• Positive, adaptable, and solutions-oriented 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

This position requires up to 5% travel.