Director of Claims & Stop-Loss Transformation - REMOTE
S&S HealthAbout the role
Reflect Health is the evolution of S&S Health, a trusted independent third-party administrator founded in 1994 to meet the growing need for access, simplified connectivity, and benefits administration. Headquartered in Mason, OH, we have built a reputation based on innovation, service excellence, and a deep understanding of how to drive better outcomes at lower cost. Over the years, we grew into a national presence serving employers, TPAs, health systems, and benefit consultants across all 50 states. We developed proprietary claims technology, expanded our offerings to include level-funded and fully funded programs, and delivered tangible savings and enhanced experiences for millions of members.
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, 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.
Responsibilities
Transformation Strategy & Future-State Design
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.
Business Process Transformation
- 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.
Claims & Stop-Loss Modernization
- 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.
Technology Enablement & Automation
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