Director of Claims

About Crumdale Specialty:

Crumdale Specialty is a diversified insurance firm providing custom, self-funded healthcare solutions to a limited distribution network of brokers, consultants, and agents nationwide. Ranked on the Inc. 5000 Fastest Growing Companies and Best Workplaces, we leverage industry expertise, superior talent, data analytics, and a disruptive mindset to manufacture, underwrite, and administer agile, transparent, and cost-saving solutions. We optimize the fragmented health benefits supply chain to reduce health benefit costs and create better outcomes for employers and employees.

At Crumdale, people come first. We strive to make a positive impact on the people we serve. We believe this starts with the passion and purpose of our team. Our company culture is rooted in alignment, innovation, and integrity.

About the Job:

The Director of Claims oversees the end-to-end claims processing operations for our self-funded health plans, ensuring accurate, timely, and compliant claims adjudication in a Third-Party Administrator (TPA) environment. The Director will drive operational excellence, ensure regulatory compliance, and improve cost efficiency while maintaining a high level of client and member satisfaction.

Key Responsibilities:

• Claims Operations Oversight: Maintains a clear understanding of Plan Documents, SBCs, and Certificates. Interprets plan language and reinsurance policy language. Supports the implementation of new and renewal clients, account management, and sales by consolidating information for implementation and/or renewal to ensure the accuracy of benefits. Builds health plans and amends the plans in the claims system.
• Process Optimization: Develop and implement strategies to streamline claims workflows, reduce processing times, and minimize errors, leveraging data analytics and automation tools. Manages claims system and standardizes procedures to increase auto adjudication (AA), AI and overall automation of claims processing.
• Vendor & Network Coordination: Collaborate with healthcare providers, stop-loss carriers, and network administrators to negotiate contracts, resolve claims disputes, and ensure seamless integration of claims data via APIs and file feeds.
• Compliance & Reporting: Ensure claims operations adhere to regulatory requirements and industry standards, maintaining accurate records and generating reports on claims performance, utilization, and cost trends for clients and leadership.
• Technology Integration: Work with IT and data teams to integrate claims systems with platforms like Salesforce, ensuring robust data pipelines and real-time reporting capabilities.
• Client Engagement: Partner with account management teams to address client needs, configure custom claims processes, and provide technical support for client-specific file feeds and API integrations.
• Cost Control: Identify opportunities to reduce administrative costs and negotiate favorable rates with providers, using data-driven insights to optimize claims spending.

Qualifications:

• Bachelor’s degree in Healthcare Administration, Business, Information Technology, or a related field preferred (or equivalent experience).
• 7–10+ years of experience in healthcare claims management, with at least 3–5 years in a leadership role within a TPA or self-funded health plan environment.
• Deep knowledge of claims adjudication processes, including EDI transactions (e.g., 837, 835), medical coding (ICD-10, CPT), and healthcare data standards (HL7, FHIR).
• Proven experience managing file feeds (SFTP, FTP, EDI) and APIs for claims and eligibility data exchange in a healthcare setting.
• Strong understanding of TPA operations, self-funded health plans, and stop-loss insurance.
• Familiarity with regulatory requirements, including HIPAA, ERISA, and ACA compliance.
• Proficiency with claims management software, CRM platforms (e.g., Salesforce), and analytics tools (e.g., SQL, Tableau).
• Excellent leadership, communication, and problem-solving skills, with the ability to manage cross-functional teams and client relationships.
• Experience with process automation, cloud platforms (e.g., AWS, Azure) is a plus.

Preferred Skills:

• Certification in healthcare administration or claims management.
• Familiarity with healthcare payer platforms and eligibility/claims systems.
• Knowledge of advanced analytics for claims trend analysis and forecasting.
• Prior success in implementing technical solutions to improve claims processing efficiency.

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 will not be engaging with external recruitment agencies. We kindly request that agencies refrain from contacting us regarding this position.