Senior Director, Stop Loss and Funding Ops

About the role

The Senior Director, Stop Loss & Funding Operations leads the end-to-end operational administration of medical stop-loss coverage, client claim funding, and premium funding for the organization’s self-funded clients. This leader has direct people-leadership accountability for assigned employees and provides functional leadership to an extended team of cross-functional partners who contribute to stop-loss and funding outcomes.

Responsibilities

• Ensure operational processes, policies, systems, and controls are aligned with stop-loss contract provisions, plan documents, eligibility requirements, and reimbursement terms.
• Provide oversight of high-cost claimant identification, reimbursement submissions, recovery efforts, carrier communications, appeals, and operational compliance.
• Manage carrier and stop-loss vendor relationships, including performance monitoring, audits, issue resolution, and operational effectiveness.
• Develop operational reporting, performance metrics, dashboards, and quality initiatives to improve reimbursement recovery, service delivery, and operational efficiency.
• Serve as the senior escalation point for complex reimbursement issues, contractual interpretations, audit findings, and client-impacting operational concerns.
• Direct operational processes supporting client claim funding, including funding calculations, cash calls, prefunding requirements, reconciliation activities, and exception management.
• Ensure accurate and timely reconciliation of client funding, paid claims, stop-loss reimbursements, refunds, and outstanding balances in partnership with Finance and Claims.
• Oversee premium-funding operations, including premium calculations, invoicing, collections, reconciliations, remittance coordination, and delinquency management.
• Establish and maintain strong financial controls, reporting processes, audit trails, and documentation standards that support contractual, regulatory, and business requirements.
• Monitor and communicate financial risks, unresolved variances, funding gaps, and operational exposures to leadership and key stakeholders.
• Lead, develop, and mentor managers and team members through effective coaching, performance management, goal setting, and professional development.
• Build organizational capability through workforce planning, succession planning, cross-training, onboarding, and talent development initiatives.
• Establish clear governance, service expectations, accountability measures, and escalation protocols across direct and cross-functional teams.
• Foster a culture of collaboration, ownership, operational excellence, innovation, and continuous improvement.
• Partner with Product, Claims, Clinical, Finance, Technology, Client Management, and Data teams to support operational readiness, process improvements, and new product capabilities.
• Translate business and carrier requirements into scalable operational workflows, procedures, system enhancements, training materials, and reporting solutions.
• Drive modernization and automation initiatives that improve efficiency, reduce risk, enhance reporting, and strengthen the client experience.
• Support client-facing teams by providing operational expertise, reimbursement updates, issue resolution, and analytical insights.

Qualifications

• Bachelor's degree in Business, Healthcare Administration, Finance, Insurance, or a related field, or an equivalent combination of education and experience.
• 10+ years of progressive leadership experience in stop-loss administration, self-funded health plans, claims operations, funding operations, or a related healthcare/insurance environment.
• 5+ years of experience leading managers and operational teams, including responsibility for employee development, performance management, workforce planning, and cross-functional collaboration.
• Strong knowledge of stop-loss administration, reimbursement processes, policy and contract interpretation, high-dollar claims, and carrier requirements.
• Proven ability to improve operational performance through process optimization, controls, automation, and risk management.
• Exceptional analytical, problem-solving, communication, and stakeholder management skills, with the ability to influence decisions and lead through complexity.

Skills

• Leadership and management skills
• Operational process management
• Financial management and reporting
• Contract interpretation and negotiation
• High-dollar claim management
• Collaboration and teamwork
• Strategic planning and execution

Benefits

• Medical, Dental and Vision and Prescription Drug Coverage
• Employee Assistance Program
• Flexible Spending Account & Health Savings Account
• 401(k) and Quarterly Bonuses
• Grossly generous Paid-Time Off & Volunteering Opportunities
• Educational Assistance & Professional Development Opportunities