AVP of Claims, Fraud & Financial Crimes – Life, Health & Annuities

Claims Operations & Governance

• Lead the execution and continual enhancement of claims programs, policies, procedures, and operational practices across Life Insurance, Health Insurance, and Annuity products.
• Ensure claims processes balance member advocacy, regulatory compliance, operational efficiency, and financial stewardship.
• Oversee the investigation, evaluation, adjudication, and resolution of complex, contestable, and sensitive claims.
• Maintain governance frameworks, operational controls, and quality standards to ensure consistency and accuracy of claims decisions.
• Identify opportunities to improve claims processes, service delivery, and member outcomes through process optimization and technology enablement.

Complex Claims Oversight

• Provide leadership and decision authority for the most complex, high-risk, contestable, and high-value claims, including settlements exceeding established authority limits.
• Partner with Legal, Medical, Compliance, and Risk stakeholders to evaluate claims involving elevated legal, regulatory, financial, or reputational risk.
• Review emerging claims trends and operational metrics to identify opportunities for improved outcomes and risk mitigation.
• Ensure timely and fair claim resolution while maintaining adherence to regulatory requirements and internal standards.

Fraud & Financial Crimes Management

• Lead fraud prevention, detection, investigation, and reporting programs supporting Life Company products and services.
• Oversee fraud governance, monitoring activities, investigative processes, and case management practices designed to protect members and the organization from financial loss.
• Drive implementation of fraud risk management strategies and control frameworks that address operational, business, and financial risks.
• Partner with Enterprise Fraud, Compliance, Legal, and Risk Management teams to strengthen fraud prevention capabilities and ensure regulatory compliance.
• Monitor emerging fraud threats, industry trends, and evolving financial crime risks and develop recommendations to enhance program effectiveness.

Anti-Money Laundering (AML) & Compliance

• Serve as the primary Life Company leader responsible for execution and oversight of AML programs and related regulatory requirements.
• Ensure compliance with applicable Bank Secrecy Act (BSA), AML, fraud, and insurance regulatory requirements.
• Partner with Enterprise Compliance, Legal, and Risk partners to implement AML policies, standards, and controls within Life Company operations.
• Maintain awareness of regulatory developments impacting claims, fraud, AML, and financial crimes programs.
• Support regulatory examinations, audits, and reviews and ensures timely remediation of identified issues.

Risk Management & Regulatory Support

• Identify, assess, monitor, and escalate operational, regulatory, compliance, and reputational risks associated with claims and fraud activities.
• Collaborate with business partners to implement effective risk mitigation strategies and sustainable control environments.
• Support interactions with state insurance departments, regulatory agencies, external auditors, and internal governance forums.
• Ensure operational practices remain aligned with applicable laws, regulations, and company policies.

Data Analytics & Process Excellence

• Utilize operational metrics, analytics, and performance data to improve claims outcomes, fraud detection effectiveness, member satisfaction, and operational efficiency.
• Lead continuous improvement initiatives focused on enhancing quality, productivity, compliance, and service delivery.
• Partner with Technology and Operations teams to implement automation, workflow improvements, and innovative solutions that improve organizational performance.
• Establish and monitor performance indicators that support effective management of claims and fraud operations.

Leadership & Talent Development

• Lead, develop, and inspire high-performing teams through coaching, mentoring, performance management, and career development.
• Create a culture of accountability, collaboration, operational excellence, and continuous learning.
• Build organizational capabilities needed to support business growth, evolving risks, and increasing regulatory expectations.
• Oversee workforce planning, succession planning, and employee engagement initiatives for assigned teams.

• Bachelor's degree, or 4 additional years of related experience beyond the minimum required may be substituted in lieu of a degree.
• 10+ years of progressive experience across Life Insurance claims, fraud prevention, financial crimes, risk management, and/or related insurance operations.
• 6+ years of leadership experience building and leading claims, SIU/fraud, financial crimes, risk, compliance, or complex operational teams.
• Deep knowledge of Life Insurance, Health Insurance, and/or Annuity claims administration, including the regulatory, operational, and customer considerations associated with complex claims.
• Demonstrated experience managing contestable claims, complex investigations, high-risk settlements, and claims involving potential fraud or material misrepresentation.
• Strong knowledge of fraud prevention, investigative practices, AML, financial crimes, operational risk, and associated governance and control frameworks.
• Proven ability to strengthen claims and investigative operations through process improvement, data and analytics, automation, technology, and disciplined performance management.
• Experience establishing and monitoring performance standards across claims quality, accuracy, cycle time, productivity, customer experience, investigative effectiveness, and financial outcomes.
• Experience working effectively with state insurance regulators, auditors, Compliance, Legal, Risk, and other control partners in highly regulated environments.
• Demonstrated ability to balance member advocacy with investigative rigor, regulatory requirements, sound risk management, and financial stewardship.
• Strong executive presence with the ability to influence senior stakeholders and drive complex decisions across a highly matrixed organization.
• Exceptional analytical, problem-solving, communication, and judgment skills, particularly when navigating complex or sensitive claims and investigative matters.

• Deep leadership experience within a prominent Life Insurance organization, with end-to-end accountability for large-scale claims operations and a strong understanding of the policyholder journey, regulatory environment, and unique complexities of life claims.Broad claims expertise across Life Insurance, Annuities, and/or Health Insurance, including significant experience with complex and contestable claims, beneficiary disputes, medical record reviews, high-risk settlements, and sensitive member or beneficiary situations.
• Demonstrated leadership of Special Investigations, fraud prevention, and financial crimes capabilities, with hands-on experience strengthening investigation, detection, escalation, and control frameworks while protecting both policyholders and the financial integrity of the organization.
• Proven success modernizing claims and investigative operations through process redesign, data and analytics, automation, and technology, materially improving claim accuracy, cycle times, investigative effectiveness, member experience, and operational efficiency.
• A track record of leading large, multi-layered Claims and Special Investigations organizations, developing strong leaders while creating a culture that balances member advocacy and empathy with investigative rigor, sound judgment, accountability, and disciplined risk management.
• Extensive experience partnering with Legal, Compliance, Risk, regulators, and other control functions on complex claims, fraud, AML, and financial crime matters, with the executive judgment to navigate situations carrying significant regulatory, financial, and reputational implications.