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S&S Health

Your health. Your way.

Director of Claims – Stop-Loss Transformation

DirectorDirectorFull TimeRemoteLeadTeam 51-200Since 1994H1B No SponsorCompany SiteLinkedIn

Location

Ohio

Posted

1 day ago

Salary

$120K - $160K / year

Seniority

Lead

Bachelor DegreeEnglish

Job Description

Director of Claims – Stop-Loss Transformation

S&S Health

• Lead strategic modernization initiatives that advance the future capabilities of our claims and stop-loss platforms. • Assess current-state capabilities, identifying operational gaps, designing future-state operating models, and leading complex initiatives. • Partner closely with Executive Leadership, Claims Operations, Stop-Loss, Technology, Finance, Compliance, Client Success, and operational teams to evaluate current performance. • Redesign workflows, establish accountability structures, and execute transformation initiatives that enable operational excellence. • Evaluate current-state claims and stop-loss capabilities, including processes, technology platforms, organizational structures, workflows, controls, compliance posture, and performance trends. • Conduct structured assessments and develop future-state operating models, transformation strategies, and implementation roadmaps.

Job Requirements

  • Significant leadership experience within a third-party administrator (TPA), self-funded health plan, managed care, or health insurance organization.
  • Deep understanding of claims operations, stop-loss administration, employer-sponsored health plans, and healthcare administration workflows.
  • Experience with self-funded plan mechanics, ASO arrangements, stop-loss contract structures, and carrier relationships preferred.
  • Knowledge of employer group, broker, TPA, and stop-loss carrier dynamics.
  • Demonstrated success leading healthcare transformation initiatives, business process redesign, operational modernization, and enterprise change programs.
  • Experience developing future-state operating models, transformation roadmaps, and scalable operating processes.
  • Proven ability to identify operational gaps, define improvement opportunities, and drive implementation across organizational boundaries.
  • Ability to influence executive stakeholders and lead complex initiatives involving multiple business functions.
  • Experience partnering 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 improving claims accuracy, workflow efficiency, operational performance, and service-level outcomes.
  • Understanding of stop-loss administration processes, including specific and aggregate claims, filing requirements, recoveries, and carrier coordination.
  • Familiarity with healthcare compliance requirements, including No Surprises Act, ACA reporting, and Continuity of Care requirements preferred.
  • Strong analytical, strategic thinking, and problem-solving capabilities.
  • Excellent communication and stakeholder management skills.
  • Ability to translate complex operational challenges into actionable transformation strategies.

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