Process Improvement Analyst – P&C Claims
Berkshire Hathaway GUARD Insurance Companies
Director – Stop Loss Operations
Crumdale Specialty
full-time
Posted on:
Location Type: Hybrid
Location: Paoli • Pennsylvania • 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- - 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.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
stop loss claims processingclaims managementfinancial reconciliationdata analysisclaims auditingpolicy administrationnegotiationregulatory complianceperformance metricsAPI integration
Soft skills
leadershipmentoringcollaborationcommunicationanalytical skillsproblem-solvingteam developmentaccountabilityadaptabilityinterpersonal skills
