Director of Claims & Stop-Loss Transformation - REMOTE

Responsibilities

• Evaluate current-state claims and stop-loss capabilities, including processes, technology platforms, organizational structures, workflows, controls, compliance posture, and performance trends.
• Conduct structured assessments to identify operational gaps, root causes, scalability challenges, and improvement opportunities.
• Develop future-state operating models, transformation strategies, and implementation roadmaps aligned with Reflect Health’s long-term growth objectives.
• Establish transformation priorities, milestones, implementation plans, and success measures.
• Provide executive leadership with strategic recommendations, business cases, and investment priorities for transformation initiatives.
• Establish baseline KPIs, operating cadences, and accountability structures to measure transformation progress.
• Lead enterprise process redesign initiatives focused on simplifying workflows, reducing administrative complexity, improving operational scalability, and enhancing service performance.
• Conduct process assessments, workflow analysis, process mapping, and root-cause evaluations to identify improvement opportunities.
• Redesign workflows and operating models to improve efficiency, quality, and consistency, as well as the development of standardized procedures, governance models, and operational accountability structures.
• Facilitate cross-functional design sessions to develop sustainable future-state processes.
• Lead modernization efforts across claims and stop-loss administration, including specific and aggregate claim processes, reporting workflows, filing timelines, and recovery processes.
• Evaluate end-to-end claims workflows, including intake, adjudication, payment, quality processes, and exception management, to identify opportunities for improvement.
• Support initiatives that improve claims effectiveness, operational consistency, automation, and organizational readiness.
• Partner with Operations leaders to improve claims quality frameworks, root-cause feedback loops, and continuous improvement practices.
• Audit opportunities to improve plan configuration discipline, auto-adjudication rates, eligibility administration, and EDI processes.
• Support automation opportunities for high-dollar claim identification, filing triggers, and exception management.
• Establish transformation governance frameworks, initiative tracking, executive reporting, and benefit realization processes.
• Define transformation success measures related to claims performance, operational efficiency, stop-loss effectiveness, automation adoption, and service improvements.
• Develop executive-level dashboards and communications related to transformation initiatives.
• Provide leadership visibility into progress, risks, dependencies, and outcomes.
• Lead organizational change efforts required to successfully implement new processes, technologies, and operating models.
• Build alignment among teams, and facilitate communication, adoption planning, and organizational readiness activities.
• Partner with operational leaders to ensure redesigned processes are successfully implemented and sustained.

Qualifications

• 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.
• 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 leveraging operational data, reporting tools, and analytics to identify root causes and support business decisions.
• Familiarity with claims technology platforms, workflow tools, automation solutions, and operational reporting capabilities.
• 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.
• Ability to operate effectively in environments requiring cross-functional influence, organizational change, and continuous improvement.