Director of Claims & Stop-Loss Transformation

Role Description

We are seeking a Director of Claims & Stop-Loss Transformation to lead strategic modernization initiatives that advance the future capabilities of our claims and stop-loss platforms. Reporting to the Chief of Staff, Transformation Office, this role serves as a transformation leader responsible for:

• Assessing current-state capabilities
• Identifying operational gaps
• Designing future-state operating models
• Leading complex initiatives that improve scalability, efficiency, quality, and organizational performance

This role will 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
• Execute transformation initiatives that enable operational excellence

The ideal candidate is an experienced healthcare transformation leader with expertise in:

• Self-funded health plan administration
• Claims operations
• Stop-loss administration
• Business process redesign
• Technology enablement
• Operational analytics
• Organizational change management

This individual must be comfortable operating as both a strategic transformation leader and a hands-on operator capable of driving measurable improvements across core TPA functions.

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
• 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 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

Requirements

• 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
• Facilitate cross-functional design sessions to develop sustainable future-state processes
• Lead modernization efforts across claims and stop-loss administration
• Evaluate end-to-end claims workflows 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 and continuous improvement practices
• Support automation opportunities for high-dollar claim identification and exception management
• Drive alignment between business strategy, operational needs, and technology investments

Benefits

• Reflect Health is committed to providing a safe and secure workplace for all employees
• All final candidates will be subject to background checks and drug screening as part of the hiring process