Director of Claims – Stop-Loss Transformation

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Spearhead strategic modernization efforts that enhance the future capabilities of our claims and stop-loss platforms.

• Evaluate existing capabilities, pinpoint operational deficiencies, design future-state operating models, and oversee intricate initiatives.

• Collaborate closely with Executive Leadership, Claims Operations, Stop-Loss, Technology, Finance, Compliance, Client Success, and operational teams to assess current performance.

• Redefine workflows, establish accountability frameworks, and implement transformation initiatives that promote operational excellence.

• Analyze current-state claims and stop-loss capabilities, encompassing processes, technology platforms, organizational structures, workflows, controls, compliance posture, and performance trends.

• Conduct structured evaluations and create future-state operating models, transformation strategies, and implementation roadmaps.

⛳️ Requirements

• Extensive leadership experience within a third-party administrator (TPA), self-funded health plan, managed care, or health insurance organization.

• Profound knowledge of claims operations, stop-loss administration, employer-sponsored health plans, and healthcare administration workflows.

• Preferred experience with self-funded plan mechanics, ASO arrangements, stop-loss contract structures, and relationships with carriers.

• Familiarity with employer group, broker, TPA, and stop-loss carrier dynamics.

• Proven track record in leading healthcare transformation initiatives, business process redesign, operational modernization, and enterprise change programs.

• Experience in developing future-state operating models, transformation roadmaps, and scalable operating processes.

• Established ability to identify operational deficiencies, define improvement opportunities, and drive implementation across organizational boundaries.

• Capacity to influence executive stakeholders and lead complex initiatives involving multiple business functions.

• Experience collaborating with Technology teams to implement workflow automation, platform enhancements, data improvements, and operational enablement solutions.

• Strong understanding of healthcare administration systems, EDI transactions, claims workflows, and operational processes.

• Experience in enhancing claims accuracy, workflow efficiency, operational performance, and service-level outcomes.

• Knowledge of stop-loss administration processes, including specific and aggregate claims, filing requirements, recoveries, and coordination with carriers.

• Familiarity with healthcare compliance requirements, including the No Surprises Act, ACA reporting, and Continuity of Care requirements preferred.

• Strong analytical, strategic thinking, and problem-solving skills.

• Excellent communication and stakeholder management abilities.

• Ability to translate complex operational challenges into actionable transformation strategies.

🏝️ Benefits

• Comprehensive health and wellness benefits.

• Retirement savings plan with employer matching.

• Opportunities for professional development and career advancement.

• Flexible work arrangements to promote work-life balance.