Non-Executive Director — Health-Insurance Administration Company | Claims Fairness, Health-Data Governance and Provider-Network Integrity

The operating mandate

The company administers health-insurance and benefit claims on behalf of regulated risk carriers and institutional customers. Its work may include member onboarding, authorisation, provider coordination, claim scrutiny, adjudication support, settlement workflow, fraud control, grievance handling and health-data processing. It does not determine the underlying insurance promise unilaterally, but its operating decisions materially influence whether a member receives timely, fair and understandable service.

The Board seeks a Non-Executive Director who can strengthen governance at the point where clinical information, policy interpretation, provider conduct, technology and financial incentives meet. The position calls for someone who understands that claims efficiency is not synonymous with claim suppression, and that fraud control must be precise enough to avoid creating systematic hardship for legitimate members.

The appointee will help the Board develop a durable service model in which operational accuracy, customer protection, regulatory conduct and unit economics reinforce each other. The Director will be expected to challenge incentives, automation or contractual service levels that produce superficially attractive turnaround times while transferring unresolved work, documentation burden or financial distress to members and providers.

Nine accountability domains

1. Claims fairness and consistency. Oversee the translation of policy terms and benefit rules into operating decisions. Similar fact patterns should produce consistent outcomes, while genuine clinical differences remain capable of reasoned review. Denials, deductions and partial approvals must carry intelligible grounds linked to the applicable contract.

2. Medical judgment and escalation. Ensure clinical questions are reviewed by appropriately qualified professionals operating independently of volume or savings targets. High-consequence decisions, unusual treatment paths, emergency cases and disputes over medical necessity require clear escalation and documented reasoning.

3. Cashless authorisation discipline. Review response standards, information requests, provisional decisions, extensions, discharge delays and communication among member, provider and insurer. Operational queues should distinguish routine incompleteness from cases where delay could cause clinical or financial harm.

4. Health-data protection. Govern collection, purpose, access, sharing, retention, correction and deletion of medical, identity, family and financial information. Sales, analytics and support teams should receive only the minimum information needed for their role. Production data must not migrate into uncontrolled test, messaging or spreadsheet environments.

5. Provider-network integrity. Examine empanelment, ownership, credentials, tariff arrangements, quality signals, conflicts, unusual utilisation, suspension and exit. Network breadth should not be promoted without evidence that providers are active, reachable and capable of delivering the represented services.

6. Fraud, waste and abuse controls. Require risk-based detection, evidence standards, investigator competence, provider and member due process, recovery governance and monitoring for model bias. Suspicion scores must not become automatic denial decisions without accountable review.

7. Technology and automation governance. Oversee rule configuration, policy-version control, clinical coding, workflow access, algorithm validation, change management, audit trails and outage resilience. Automated adjudication must retain explainability, exception handling and clear human ownership.

8. Client and regulatory contract integrity. Review service responsibilities, delegated authority, turnaround definitions, data roles, audit rights, liability, subcontracting, complaints, transition assistance and termination. The company must know which obligations belong to the insurer, employer, provider and administrator, and must not quietly absorb unpriced regulated responsibility.

9. Economics without customer harm. Examine revenue per member or transaction alongside clinical-review effort, technology cost, provider operations, complaint handling, information security, audit burden and receivable days. Productivity programmes should be tested for downstream denial, repeat contact, delayed discharge and grievance cost.

Decisions that should reach the Board

The NED will bring independent-minded challenge to major payer or employer contracts; expansion of delegated claims authority; new clinical or fraud analytics; entry into additional benefit categories; acquisitions; provider-network partnerships; offshore or outsourced processing; material cyber investment; insurance and indemnity arrangements; and any remediation involving significant member harm.

Every major contract should state the exact decision rights, required clinical capability, service-volume assumptions, turnaround measurement, data movement, member communication, complaint responsibility, liability boundaries, technology changes and credible exit plan. Commercial attractiveness must be assessed after the full cost of safe and fair administration.

Claims and customer-protection scorecard

The Board should receive more than a single approval rate or average turnaround time. Reporting should distinguish emergency and planned cases; complete and incomplete submissions; full, partial and denied claims; decision reversals; discharge delays; member out-of-pocket consequences; complaints by allegation; grievance ageing; provider disputes; suspected fraud outcomes; data-access exceptions; algorithm overrides; system availability during critical periods; regulatory observations; client concentration; and cash conversion.

The Director should require periodic file-level assurance that traces selected cases from member eligibility and policy version through medical review, decision, communication, settlement and grievance. Assurance should test whether reasons were accurate, evidence was complete, data access was justified and any automated recommendation was used within its approved scope.

Leadership profile

Candidates should bring at least 22 years of senior experience across insurance, healthcare, claims, managed care, clinical governance, financial services operations, customer protection, technology risk, data privacy, audit or regulated-company boards. Suitable backgrounds may include former CEOs, COOs, CFOs, claims leaders, medical governance executives, chief risk officers, information-security leaders or experienced Non-Executive Directors.

The Board particularly values the ability to understand a member's journey alongside contract economics and control evidence. Experience with high-volume regulated operations, health data, provider networks, complex complaints, outsourcing, automation or material incident response will be advantageous.

Eligibility and conflict requirements

IICA Independent Directors Databank registration is not required. The successful candidate must nevertheless meet all legal, regulatory, director-identification, consent, disclosure, fit-and-proper and conflict requirements applicable to the appointment and the company's regulated activities.

All relationships involving insurers, employers, hospitals, clinics, diagnostic providers, pharmaceutical or medical-device businesses, brokers, technology vendors, auditors, investors, lenders or outsourced service providers must be disclosed. The Board seat may not be used to generate referrals, provider empanelment, insurance distribution, technology sales, clinical volume or consulting assignments for a connected party.

First six months

The NED will trace representative claims across approval, denial, reversal and grievance pathways; review cases involving emergency or financial hardship; examine provider onboarding and suspension; test high-risk access to health data; review the logic and oversight of automated decisions; and reconstruct the economics of major service contracts after complaints, clinical review and technology obligations.

Early success will be visible through sharper Board reporting, clearer decision rights, protected clinical escalation, better denial explanations, stronger data access, fairer grievance handling and management incentives that reward accurate resolution rather than inexpensive closure.

Twelve-month contribution expected

Within one year, the company should demonstrate consistent claims decisions, clinically accountable escalation, usable provider governance, defensible fraud controls, stronger health-data stewardship and customer metrics capable of revealing harm rather than averaging it away. The NED's contribution should help make trust and fairness operating assets, not compliance language.