Global Benefits-Claims Integrity Director

The mandate

Employees move between hourly, salaried, leave and disability status through systems that do not update benefit administrators consistently. Recent escalations involve denied health claims after eligibility feeds failed, disability cases crossing occupational and insured processes, and appeals closed because evidence reached the wrong vendor queue. Benefits reports emphasise total cost and service levels but do not show preventable coverage breaks, repeat denial reasons or financial hardship while cases move. The group needs governance that tests protection promised against protection actually delivered.

The deliverables are a benefit-and-vendor taxonomy, eligibility lineage, claim-and-appeal journey, denial diagnostic, clinical-decision boundary, employee support standard, control design and implementation roadmap. The work must cover enrolment, life events, payroll deductions, leave, disability, plan transitions, provider bills, prior authorisation, denial notices, appeals, vendor handoffs, payment and recovery. Medical necessity and clinical judgement must remain with authorised clinicians and plan fiduciaries rather than HR operations.

Four milestones govern five months: week four accepts plans, populations, jurisdictions and protected-data protocol; week nine completes eligibility and denial diagnostics; week fifteen accepts target journeys, vendor accountabilities and controls; and week twenty-two delivers simulation evidence, monitoring, contractual remedies and rollout backlog. Billing follows those milestones, and live individual appeals remain with established administrators, fiduciaries, counsel or independent reviewers.

Acceptance requires benefits and payroll owners to reproduce representative eligibility changes, vendors to trace selected claims and appeals without revealing unnecessary diagnosis, and employee support teams to navigate two simulated complex journeys correctly. The design must distinguish administrative error, plan exclusion, clinical denial, missing evidence, provider billing issue and appeal failure. The sponsor returns one consolidated issue log within seven working days of each milestone.

The client provides plan documents, eligibility files, payroll deductions, de-identified claims and denials, appeal timing, vendor contracts, complaints, leave events, fiduciary and counsel guidance and secure analytical access. The consultant does not adjudicate claims, interpret plan law, access unnecessary clinical records, contact employees about live cases, determine disability or medical necessity, direct payment, or replace fiduciary and insurer authority.

Why this is external work

Benefits teams see plan design and cost, administrators see transactions and employee relations sees hardship after failure, but no owner tests the whole protection journey. Vendors also describe performance within their own queues rather than across handoffs. Independent benefits-claims expertise can diagnose preventable failure and strengthen accountability without deciding clinical eligibility or selling insurance placement.

What you will own

• Map plan eligibility from hire, status, deductions, life event, leave, disability, return and termination across system owners.
• Classify claim outcomes by administrative error, exclusion, clinical decision, evidence gap, provider billing and appeal-process failure.
• Trace de-identified employee journeys across providers, administrators, insurers, occupational health, payroll and support teams.
• Define support standards for notices, escalation, translation, financial hardship, protected information and independent appeal rights.
• Establish vendor accountability for feed acceptance, case ownership, transfer, response, clinical separation, audit trail and closure.
• Run complex simulations and measure preventable coverage break, denial recurrence, appeal delay and unresolved handoff risk.
• Deliver controls, monitoring, contract remedies, employee guidance, ownership and a prioritised implementation backlog.

Candidate qualifications

• Has redesigned health, disability or insured-benefit claims governance for a large multi-country or multi-plan employer.
• Understands eligibility feeds, payroll deductions, leave events, claims, denials, appeals, fiduciary and clinical decision boundaries.
• Can analyse protected claims pathways using de-identified evidence and strict minimum-necessary access.
• Has resolved systemic vendor handoff failure without taking authority over medical necessity or individual adjudication.
• Brings credible collaboration with benefits, payroll, leave, privacy, clinicians, fiduciaries, insurers and employee support.
• Is independent of insurance brokerage, claims administration sales, clinical referrals and benefit-technology placement.

Non-negotiables

• Can attend monthly Atlanta governance weeks and both employee-journey simulations despite remote delivery.
• Brings direct claims and appeal operations; benefit procurement or wellness programme experience alone is insufficient.
• Will not adjudicate live claims, access unnecessary diagnosis, promise coverage or override clinical and fiduciary authority.
• Will disclose relationships with insurers, administrators, brokers, clinical vendors, fiduciaries and technology providers.

1. 49 words maximum. Which evidence separates an eligibility-feed failure from a valid plan exclusion?
2. 49 words maximum. How would you test an appeal handoff without accessing unnecessary diagnosis?
3. 49 words maximum. What outcome metric reveals employee harm hidden by average vendor response time?