Process Consultant, Stop Loss Claims

Process Consultant, Stop Loss Claims

The opportunity:

The Process Consultant, Stop Loss Claims is accountable for process governance, end-to-end documentation strategy, and continuous improvement that strengthens quality, compliance, scalability, and risk management within Stop Loss Claims Operations.

This role translates complex adjudication and system workflows into standardized, auditable, and future-ready operating models. The role partners closely with senior leaders across Claims, Compliance, Quality, Audit, IT, and Learning to reduce variation, enable change, and drive measurable operational outcomes.

This position is suited for an experienced claims professional who influences beyond direct authority, anticipates downstream risk, and elevates the organization through disciplined process design and governance.

How you will contribute:

Process Governance & Enterprise Documentation Strategy

• Support the end-to-end governance framework for all Stop-Loss Claims processes, SOPs, templates, and workflows.
• Establish standards for documentation quality, structure, version control, approval, and lifecycle management.
• Ensure all documentation remains audit-ready and aligns with regulatory requirements, system capabilities, and evolving business strategy.
• Serve as a primary process SME during internal and external audits, regulatory reviews, and risk assessments.
• Provide expert guidance to leaders on process controls, documentation risk, and remediation strategies.

Process Excellence, Standardization & Optimization

• Lead complex, cross-functional process evaluations to identify inefficiencies, control gaps, and variation impacting quality, cost, or member experience.
• Design and implement standardized, scalable process solutions that improve accuracy, throughput, and operational resilience.
• Analyze audit findings, QA trends, operational metrics, and error patterns to inform improvement roadmaps.
• Apply systems thinking and continuous improvement methodologies to proactively strengthen upstream and downstream processes.

Strategic Stakeholder Partnership

• Act as a liaison across Claims Operations, QA, Compliance, Audit, Legal, IT, and Learning & Development.
• Influence decision-making by clearly articulating risk, impact, and trade-offs tied to process or system changes.
• Support system and technology initiatives by defining business requirements, documenting future-state workflows, and ensuring operational readiness.
• Partner with Learning & Development to ensure training strategy and materials accurately reflect approved processes and controls.

Change Leadership & Business Readiness

• Lead change planning and communication for complex, multi-stakeholder process initiatives.
• Develop adoption strategies, and implementation guidance.
• Coach leaders and teams through change by clarifying expectations, risks, and success measures.
• Ensure seamless adoption of new or revised processes with minimal disruption to operations.

Quality, Risk & Control Management

• Support the linkage between process design, quality outcomes, and regulatory compliance.
• Proactively identify process-driven risk and recommend mitigation strategies aligned to enterprise risk frameworks.
• Drive corrective and preventive actions through disciplined updates to procedures, controls, and guidance.
• Strengthening overall Claims control environment through clarity, consistency, and accountability.

What you will bring with you:

• 3+ years of progressive experience in Stop-Loss Claims or complex claims operations.
• Expertise in stop-loss adjudication, operational workflows, and regulatory considerations.
• Proven ability to design, govern, and sustain enterprise-level process documentation.
• Strong analytical and problem-solving skills with the ability to influence outcomes through insight rather than authority.
• Exceptional written and verbal communication skills, including executive-level materials.
• Demonstrated experience with cross-functional process improvement or transformation initiatives.
• Experience partnering with audit, compliance, risk, or quality organizations.
• Knowledge of how emerging technologies and AI-enabled solutions (e.g., intelligent document processing, workflow automation,…