Director of Claims – Stop-Loss Transformation
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Job Description
Director of Claims & Stop-Loss Transformation at Reflect Health managing claims operations and strategic initiatives. Evaluating current processes and designing future operating models for operational excellence.
Responsibilities:
- 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.
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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