Claims Director - REMOTE

S&S Health is a premier healthcare administration company located in Cincinnati, Ohio. We offer self, level, and fully funded solutions that lower costs while improving outcomes with a consumer-centric experience. Our integrated benefits, services, and technology platform have been developed to serve the needs of Employers, TPAs, and Health Systems. The company has a nationwide presence with the ability to sell and service in every state. 

S&S Health is looking for an experienced Claims Director to spearhead our claims operations. This pivotal role involves overseeing the entire claims process, including managing a team of supervisors, developing training materials, and creating and enforcing comprehensive documentation and SOPs. The Claims Director will lead quality assurance efforts, support crucial audits, contribute to client presentations, and provide valuable insights through detailed reports to senior leadership.

Key Responsibilities:

• Team Leadership:
  • Manage a team of supervisors and managers, including remote staff across various time zones, providing guidance, support, and professional development opportunities.
  • Support the development of training materials for claims staff, ensuring they are well-equipped to handle claims processing and customer interactions.
  • Interface with various vendors for the purpose of administering claim related provisions.
  • Coordinate with other internal divisions, including but not limited to, reinsurance, enrollment/eligibility and others as is needed.
• Process Development:
  • Develop and maintain comprehensive documentation for claims processes, including standard operating procedures and guidelines.
  • Create and implement processes for monitoring and tracking Key Performance Indicators (KPIs), ensuring they align with organizational goals and compliance standards.
  • Integrate regulatory and industry related requirements into claim processes.  
• Quality Assurance and Auditing:
  • Lead internal audits and QA efforts to verify the accuracy and quality of claims processing, ensuring compliance with industry regulations and company policies.
  • Coordinate with external auditors to support carrier, SOC2 and HITRUST audits, including testing and deployment activities.
• Presenting and Reporting:
  • Develop reports related to claims performance and operational metrics, presenting findings and insights to senior leadership.
  • Contribute to presentations for prospective clients, showcasing the effectiveness and efficiency of the claims process.

Qualifications:

• Proven experience as a Claims Director or in a similar leadership role within the self-funded or fully insured industry. 
• Experience with various healthcare benefits is a plus.
• Advanced proficiency in Microsoft Office, including Word, Power Point and Excel (VLOOKUP, Pivot Tables, etc.).
• Strong ability to develop and manage documentation, processes, and KPI tracking related to claims operations.
• Experience with quality assurance, internal auditing, and supporting external audits (SOC2, HITRUST).
• Excellent …