Director of Claims – Stop-Loss Transformation

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🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $120k - $160k / year

⏰ Full Time

🔴 Lead

👔 Director

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S&S Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1994

⚕️ Healthcare Insurance

🤝 B2B

☁️ SaaS

Healthcare Insurance • B2B • SaaS

S&S Health is a modern health administration provider dedicated to offering affordable healthcare solutions for employers and their employees. By focusing on cost management, S&S Health helps businesses reduce healthcare expenses while maintaining high-quality care. With end-to-end support, they provide tools and resources to ensure that employees have access to the right medical care at competitive prices, ultimately aiming to improve both health outcomes and financial wellbeing.

📋 Description

• 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.