Director, Claims Counsel

Metlife Legal Plans•Cleveland, OH

14h•Remote

About The Position

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 claims organization.

Requirements

Bachelor’s 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 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

Nice To Haves

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

Responsibilities

Review, adjudicate, and approve complex and high-value claims, including approvals, rejections, and adjustments, in accordance with approved fee schedules and coverage determinations
Primary focus on negotiated arrangements, pre-approved fee schedules, and escalated matters
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
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
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
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
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