Best Doctors Insurance · 15 hours ago
Claims Manager
Miami-FTL Area
Full-time
Hybrid
Senior Level, Lead/Staff
8+ years expBest Doctors Insurance is a leading international health insurance company providing high-quality healthcare solutions. The Claims FWA Manager is responsible for leading initiatives to detect, prevent, and mitigate fraud, waste, and abuse within claims operations, focusing on cost containment and operational efficiency.
Financial ServicesInsuranceMedical
Hiring Manager
Matias Borszewski
Responsibilities
Develop and implement strategies to reduce fraudulent and abusive claims, minimizing financial leakage
Analyze claims data to identify patterns, anomalies, and high-risk areas for cost containment
Lead investigations into suspicious claims and provider activities, ensuring timely resolution and recovery
Coordinate reviews with Risk and Legal areas, to ensure accurate fraud assessments
Utilize predictive modeling, data mining, and fraud detection tools to enhance claims oversight
Partner with IT teams to define requirements for fraud detection and claims analytics tools
Lead User Acceptance Testing (UAT) and oversee deployment of new systems and enhancements with embedded FWA controls
Drive automation and digitalization initiatives to improve fraud detection and claims efficiency
Work closely with Provider Relations, IT, Finance, Underwriting, Legal and Customer Service to embed FWA controls into claims workflows
Act as a key liaison for strategic projects impacting claims operations and fraud prevention
Provide regular updates to the COO on fraud trends, cost containment results, and technology initiatives
Develop dashboards and management reports highlighting fraud trends, cost savings, and operational improvements
Recommend process enhancements based on data-driven insights and emerging fraud schemes
Deliver training programs to claims teams on fraud detection techniques and cost containment strategies
Promote a culture of vigilance and accountability across claims operations
Qualification
Required
Bachelor's degree in Business Administration, Finance, Insurance, or related field
Minimum 8–10 years in health or medical insurance claims operations with a strong focus on fraud detection and cost containment
Proven track record in managing FWA programs and leading investigative teams
Expertise in claims systems, fraud detection platforms, and data analytics tools
Advanced Microsoft Excel and familiarity with SQL or similar query languages
Bilingual (Spanish and English) required
Strong analytical and investigative skills with attention to detail
Excellent communication and stakeholder engagement abilities
Ability to lead projects and thrive under pressure in a fast-paced environment
Preferred
International Health Insurer experience
Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or equivalent
Portuguese preferred
Company
Best Doctors Insurance
Best Doctors Insurance is an international private medical insurance company that offers medical insurance to private and corporate clients.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Rosmery De Leon
C- Level Business Partner to the Chief Executive Officer and Board of Directors
Ulisses Soares
Chief Executive Officer
Company data provided by crunchbase