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Director, Stop Loss Operations

Director, Stop Loss Operations

Crumdale SpecialtyPaoli, PA, US
7 days ago
Job type
  • Full-time
Job description

Job Description

Job Description

About Crumdale Specialty

Crumdale Specialty is a diversified insurance firm providing custom solutions to businesses nationwide. We leverage industry expertise, superior talent, and a disruptive mindset to deliver agile, transparent, and cost-saving solutions that optimize self-funded health plans. Our company culture is rooted in alignment, innovation, and integrity, and we are proud to be recognized as one of Inc. Magazine’s Best Places to Work.

Position Summary

The Director of Stop Loss Operations will serve as a strategic leader responsible for overseeing the administration of our stop loss business with a strong focus on the adjudication, analysis, and optimization of stop loss claims. This role will ensure accurate, timely, and compliant stop loss claims and policy administration processes while driving operational excellence. The Director will lead a team of analysts and collaborate cross-functionally with internal departments, external TPAs, external MGUs, and carrier partners to ensure best-in-class claims outcomes.

Key Responsibilities

Claims Oversight & Adjudication

  • Oversee end-to-end Specific, Aggregate, and Level-Funded stop loss claims processing, ensuring compliance with policy provisions, regulatory standards, and Crumdale’s internal protocols
  • Schedule, track, and review complex aggregate and level-funded claims and financial reconciliations for accuracy, eligibility, and reimbursement integrity
  • Ensure timely adjudication and resolution of claims, including coordination with internal departments as well as TPAs, PBMs, audit vendors, carriers, and external MGU partners

Team Leadership & Development

  • Lead, mentor, and develop a team of Stop Loss Claims Analysts
  • Establish performance metrics and ensure continuous improvement in claims operations
  • Foster a collaborative and accountable team culture

    • Carrier & Vendor Collaboration

  • Serve as a liaison with stop loss carriers for complex claims and policy administration-related matters
  • Serve as the primary liaison with external MGU partners to ensure seamless stop loss claims operations
  • Negotiate and resolve claims disputes with providers and carriers
  • Ensure seamless integration of claims data via APIs and file feeds

    • Compliance & Reporting

  • Ensure adherence to federal and state regulations, including ERISA and HIPAA
  • Maintain accurate records and generate monthly and quarterly claims performance reports
  • Support internal audits and regulatory reviews

    • Requirements

  • Bachelor’s degree in Healthcare Administration, Business, Finance, or related field; Master’s preferred
  • Minimum 5 years of progressive experience in stop loss operations and claims management or TPA claims operations
  • Strong understanding of stop loss insurance principles, including medical stop loss claims auditing and policy administration
  • Proven leadership experience in a dynamic insurance or healthcare setting
  • Exceptional communication and analytical skills with proficiency in data analysis and interpretation

    • Benefits

    At Crumdale, we strive to provide a comprehensive and supportive benefits package to ensure the well-being of our employees. Our benefits include :

  • Medical
  • Telemedicine
  • Dental
  • Vision
  • Life, AD&D, Disability
  • 401(k)
  • Flexible Time-off

    • Please note : Crumdale Specialty is not engaging with external recruitment agencies; please refrain from contacting us regarding this position.

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    Director Operation • Paoli, PA, US