We are looking for a Senior Health Claims Expert – Individual Claims to join our Life & Health Claims Division.
In this role, you will lead initiatives to detect, prevent, and mitigate Fraud, Waste, and Abuse (FWA) across health insurance claims, combining deep operational expertise with advanced analytics. You will collaborate closely with data scientists, engineers, and compliance teams to design and implement solutions that strengthen claims integrity and minimize financial risk.

What You Will Do:

Claims Expertise & Oversight

• Provide subject matter expertise on health claims processes, adjudication rules, and regulatory compliance.

• Review and validate claim patterns, anomalies, and high‑risk indicators identified through analytics.

Collaboration with Data Teams

• Partner with data analysts and engineers to define business requirements for FWA detection models.

• Translate operational insights into data features used in predictive modeling and anomaly detection.

• Validate model outputs and ensure alignment with business logic and balanced risk‑based decisions.

Fraud Detection & Prevention

• Support the development of advanced FWA strategies leveraging analytics, AI, and rule‑based systems.

• Contribute to the creation of dashboards and reporting tools for monitoring suspicious claim behaviors.

• Recommend corrective actions and process improvements based on analytical findings.

Stakeholder Management

• Communicate complex analytical insights to non‑technical stakeholders in a clear and actionable manner.

• Train claims teams (including TPA partners) on emerging fraud trends and data‑driven prevention techniques.

What You Bring:

Required

• 8+ years of experience in health claims management, including at least 3 years in fraud detection.

• Familiarity with analytics concepts (predictive modeling, anomaly detection).

• Ability to work with SQL and dashboards (Power BI/Tableau), and understand data pipelines.

• Strong understanding of the health insurance market, coding standards, and claims workflows.

• Excellent analytical thinking, communication, and stakeholder engagement skills.

Preferred

• Exposure to machine learning applications in healthcare.

• Experience with FWA tools (e.g., SAS Fraud Framework).

• Certification in fraud examination (CFE) or healthcare compliance.

What We Offer:

• Extensive training opportunities – on-demand and on-site
• Partnerships with educational institutions across Greece for advanced study, with tuition support
• Comprehensive Health Insurance for peace of mind and financial protection
• Well-being support and work–life balance
• One‑time budget for home-office equipment
• Recognition and rewards for excellence
• Monthly meal allowance
• Newly renovated, centrally located offices with easy access