Director of Claims – Stop-Loss Transformation

🕒 Julho 11

🏈 Ohio – Remoto

🏈 Ohio – Remote

💵 $120.000 - $160.000 / ano

⏰ Tempo Integral

🔴 Especialista

👔 Diretor

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S&S Health

SiteLinkedInTodas as Vagas

51 - 200 funcionários

Fundada em 1994

🏥 Saúde

🛡️ Seguros

⚕️ Seguro de Saúde

Healthcare • Insurance • Healthcare Insurance

A S&S Health é uma provedora moderna de administração de saúde dedicada a oferecer soluções de saúde acessíveis para empregadores e seus funcionários. Focando na gestão de custos, a S&S Health ajuda as empresas a reduzir despesas com saúde, mantendo cuidados de alta qualidade. Com suporte completo, a empresa fornece ferramentas e recursos para garantir que os funcionários tenham acesso ao atendimento médico adequado a preços competitivos, visando, em última análise, melhorar tanto os resultados de saúde quanto o bem-estar financeiro.

Descrição

• 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.

🎯 Requisitos

• 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.