Team Lead managing daily operations, mentoring staff, and ensuring logistics efficiency in a global transport firm.
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.
Job title
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