Director of Claims & Stop-Loss Transformation - REMOTE

S&S Healthcare•Cincinnati, OH

4d•$120,000 - $160,000•Remote

About The Position

Reflect Health is 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, and 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, and execute transformation initiatives that enable operational excellence. The ideal candidate is an experienced healthcare transformation with expertise in self-funded health plan administration, claims operations, stop-loss administration, business process redesign, technology enablement, operational analytics, and 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.

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.
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.
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.

Nice To Haves

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.
Familiarity with healthcare compliance requirements, including No Surprises Act, ACA reporting, and Continuity of Care requirements preferred.

Responsibilities

Evaluate current-state claims and stop-loss capabilities, including processes, technology platforms, organizational structures, workflows, controls, compliance posture, and performance trends.
Conduct structured assessments to identify operational gaps, root causes, scalability challenges, and improvement opportunities.
Develop future-state operating models, transformation strategies, and implementation roadmaps aligned with Reflect Health’s long-term growth objectives.
Establish transformation priorities, milestones, implementation plans, and success measures.
Provide executive leadership with strategic recommendations, business cases, and investment priorities for transformation initiatives.
Establish baseline KPIs, operating cadences, and accountability structures to measure transformation progress.
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. Establish transformation priorities, milestones, and implementation plans.
Redesign workflows and operating models to improve efficiency, quality, and consistency, as well as the development of standardized procedures, governance models, and operational accountability structures.
Facilitate cross-functional design sessions to develop sustainable future-state processes.
Lead modernization efforts across claims and stop-loss administration, including specific and aggregate claim processes, reporting workflows, filing timelines, and recovery processes.
Evaluate end-to-end claims workflows, including intake, adjudication, payment, quality processes, and exception management, to identify opportunities for improvement.
Identify opportunities to reduce claims errors, rework, pend volume, manual intervention, and service-level misses.
Support initiatives that improve claims effectiveness, operational consistency, automation, and organizational readiness.
Partner with Operations leaders to improve claims quality frameworks, root-cause feedback loops, and continuous improvement practices.
Assess opportunities to improve plan configuration discipline, auto-adjudication rates, eligibility administration, and EDI processes.
Support automation opportunities for high-dollar claim identification, filing triggers, and exception management.
Partner with Technology teams to translate business opportunities into system enhancements, automation opportunities, platform improvements, and data-driven solutions.
Support evaluation of technology capabilities and recommend enhancements that enable future-state operations.
Identify opportunities for workflow automation, TPA platform optimization, EDI improvements, and operational enablement solutions.
Drive alignment between business strategy, operational needs, and technology investments.
Support development of operational dashboards and reporting capabilities that improve leadership visibility into performance trends, risks, and opportunities.
Establish transformation governance frameworks, initiative tracking, executive reporting, and benefit realization processes.
Define transformation success measures related to claims performance, operational efficiency, stop-loss effectiveness, automation adoption, and service improvements.
Develop executive-level dashboards and communications related to transformation initiatives.
Provide leadership visibility into progress, risks, dependencies, and outcomes.
Lead organizational change efforts required to successfully implement new processes, technologies, and operating models.
Build alignment among teams, and facilitate communication, adoption planning, and organizational readiness activities.
Partner with operational leaders to ensure redesigned processes are successfully implemented and sustained.