Senior Claims Operations Specialist

Responsibilities 

Strategy Development & Execution 

• Partner with the Claims Operations Lead to develop and implement an in‑market strategy that drives end‑to‑end transformation of claims operations and claims risk management. 

• Identify opportunities to enhance operational efficiency through organisational redesign, process optimisation, automation, and technology adoption. 

• Drive initiatives to increase straight-through processing (STP), reduce manual effort, and enhance adjudication accuracy. 

• Track key KPIs to measure value realisation and operational effectiveness. 

Technology and Innovation:  

• Collaborate with AH’s product teams to design and deploy AH solutions.  

• Collaborate with the client’s technology/data teams to ensure deployment of technology/data solutions are aligned with operational needs and changes to optimize the value in delivery.  

• Work closely with technology teams to deploy AI-driven solutions for fraud detection, waste minimization, and claims adjudication.  

• Oversee the integration of advanced analytics tools and predictive models to streamline claims workflows.  

• Evaluate emerging technologies and partner with insurtech vendors to stay at the forefront of industry innovation. 

Process Optimisation 

• Lead transformation of end‑to‑end claims processes with a focus on cost and operational efficiency. 

• Implement best‑practice frameworks for quality assurance, compliance, and medical claims management. 

• Develop, monitor, and continuously refine KPIs to support improvement cycles. 

Stakeholder Engagement 

• Serve as a key liaison between underwriting, actuarial, provider management, technology, and customer service teams, to ensure seamless claims operations. 

• Translate complex business requirements into actionable technical and operational specifications. 

• Engage with regulators and providers to ensure alignment with industry standards and evolving regulatory expectations. 

• Collaborate with client stakeholders to adapt processes and SOPs, ensuring alignment with local regulations and operational needs. 

Change Management 

• Lead organisational change efforts to foster a culture of innovation and adaptability within the claims team.  

• Provide training and support to ensure smooth adoption of new processes and technologies.  

• Communicate transformation goals, progress, and outcomes to leadership and other key stakeholders.  

• Identify and close operational gaps through workflow observation, root cause analysis, and process improvement initiatives. 

Fraud, Waste, and Abuse (FWA) Management 

• Deploy advanced analytical and AI-enabled solutions to detect, prevent, and mitigate FWA.  

• Collaborate with Special Investigation Units and analytics teams to continuously refine detection models.  

• Recommend enhancements to audit frameworks and oversee tracking of value delivery. 

Provider Risk Management 

• Partner with provider management and claims teams to design and embed solutions that operationalise provider agreements.  

• Translate provider requirements into SOPs, system rules, and workflow enhancements across pre‑auth, adjudication, IGL/FGL, and claims processing.  

• Conduct workflow observations to identify opportunities to strengthen provider risk mitigation and value capture.  

Candidate Profile 

Experience and Qualifications 

• Over 7 years of experience in provider management, clinical operations, medical claims, healthcare insurance, or related fields.  

• Demonstrated experience leading claims transformation, operations improvement, or provider-management change initiatives.  

• Strong background in leveraging automation, analytics, and AI within claims workflows.  

• Familiarity with claims adjudication platforms, FWA detection tools, and data-driven operations design.  

• Prior experience in consulting (strategy, operations, health systems) preferred.  

• Medical degree (MD/MBBS) or health science advantageous; MBA or advanced degree preferred. 

Competencies & Core Characteristics: 

We are seeking a leader who embodies the following competencies and characteristics essential for success in our scale-up environment: 

• Technical Domain Expertise: Demonstrates deep understanding of medical claims operations, provider risk frameworks, and healthcare insurance processes. Applies technical knowledge to design scalable, compliant, and high‑quality solutions. Ensures decisions are grounded in clinical, operational, and regulatory accuracy. 

• Strategic Architect: Thinks systematically and anticipates long-term implications when designing policies, processes, and solutions. Develops clear strategic pathways that align operational execution with Amplify Health’s broader business objectives. 

• Unifier & Cross-Functional Influencer: Builds strong relationships across product, technology, actuarial, commercial, and provider teams. Facilitates alignment among diverse stakeholders and drives consensus in complex, multi-party environments. 

• Coach & Talent Multiplier: Elevates team capability by mentoring colleagues, sharing best practices, and enabling continuous learning. Cultivates a high-performance culture grounded in accountability and collaboration. 

• Data-Driven Decisiveness: Applies analytical rigor to interpret trends, diagnose root causes, and drive evidence-based decisions. Uses KPIs, models, and performance dashboards to guide priorities and measure outcomes. 

• Resilient Operator: Performs effectively in high‑ambiguity, fast‑paced environments. Adapts rapidly to evolving client needs, market dynamics, and organisational shifts while maintaining clarity and execution focus. 

• Customer-Obsessed Advocate: Prioritises customer impact in all decisions. Builds trusted relationships with clients, understands operational pain points, and champions solutions that deliver measurable, sustainable value. 

• Insatiable Curiosity: Constantly seeks new insights, innovations, and industry best practices. Demonstrates a growth mindset and embraces emerging technologies, methodologies, and ideas to elevate outcomes.