Hybrid Director – Stop Loss Operations

at Crumdale Specialty

• Job title: Director – Stop Loss Operations
• Job type: Full Time
• Experience level: Lead
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Paoli, United States

About the role

• Director overseeing stop loss operations at Crumdale Specialty, a diversified insurance firm. Leading claims management and team development for optimal health plan solutions.

Responsibilities

• 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
• 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
• 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
• 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.