Director Stop Loss Rn Jobs (NOW HIRING)

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Position Summary

The Lead Director, Stop Loss Relationship Management will serve as the single accountable owner for enterprise stop loss relationship strategy, governance, escalation management, and operational performance. This role is responsible for creating a more disciplined, scalable, and consistent operating model across stop loss carriers, internal business partners, and cross-functional stakeholders.

This leader will address current gaps in ownership, decision rights, escalation pathways, and carrier performance that are contributing to delays, disputes, reimbursement challenges, and financial exposure. The role will centralize accountability for stop loss-related funding decisions, risk acceptance, issue resolution, and carrier engagement, ensuring clearer governance, faster resolution of high-cost claim issues, and improved predictability across the stop loss ecosystem.

The ideal candidate is a strong enterprise relationship leader with deep experience managing complex, cross-functional programs, executive-level stakeholders, financial risk, operational escalations, and external partner performance. This individual must be highly effective at driving alignment, establishing governance, improving processes, and influencing outcomes across matrixed teams.

• Serve as the dedicated relationship owner and single point of accountability for stop loss carrier management, escalation resolution, governance, and operating discipline.
• Establish clear decision rights, escalation pathways, and enterprise guardrails for stop loss-related funding decisions, risk acceptance, reimbursement issues, and carrier disputes.
• Lead cross-functional coordination across operations, finance, claims, legal, underwriting, account management, compliance, and carrier partners to ensure consistent execution and timely resolution of stop loss issues.
• Drive improved reimbursement performance by proactively managing aged receivables, high-cost claim escalations, documentation requests, audit friction, and delayed carrier responses.
• Develop and maintain a structured carrier management model that improves consistency, leverage, predictability, and accountability across a fragmented stop loss carrier ecosystem.
• Partner with senior leaders to identify financial and operational risk, assess exposure, recommend mitigation strategies, and support timely decision-making.
• Create standardized reporting and executive-level visibility into stop loss performance, including reimbursement delays, dispute trends, escalation status, carrier responsiveness, and financial exposure.
• Identify process gaps, root causes, and recurring friction points; implement scalable solutions that reduce manual work, improve cycle time, and increase operational consistency.
• Lead governance forums, carrier reviews, and internal stakeholder updates to ensure alignment on priorities, performance expectations, and issue resolution.
• Translate complex operational, financial, and carrier issues into clear executive-ready summaries, recommendations, and decision points.
• Build strong internal and external relationships to improve accountability, reduce friction, and support long-term business growth.
• Promote a culture of ownership, disciplined execution, collaboration, and continuous improvement.

Required Qualifications

• 10+ years of experience leading complex business operations, program management, relationship management, healthcare operations, insurance operations, financial risk management, or related functions.
• Demonstrated experience managing cross-functional initiatives with senior stakeholders, external partners, and matrixed teams.
• Strong ability to establish governance, clarify decision rights, manage escalations, and drive accountability across multiple business areas.
• Experience identifying and mitigating operational, financial, legal, compliance, or reimbursement-related risk.
• Proven ability to manage complex issue resolution, including disputes, escalations, competing priorities, and time-sensitive business decisions.
• Strong financial acumen, including the ability to understand reimbursement performance, receivables, exposure, cost drivers, and operational impacts.
• Ability to create executive-level reporting, business cases, decision frameworks, and performance updates.
• Excellent communication, influencing, and relationship management skills, with the ability to engage effectively with senior leaders and external partners.
• Demonstrated ability to improve processes, implement scalable operating models, and reduce manual or reactive work.
• Strong problem-solving, prioritization, and decision-making skills in a fast-paced and complex environment.

Preferred Qualifications

• Experience with stop loss, self-funded health plans, claims operations, underwriting, medical management, reimbursement, or payer/TPA operations.
• Experience managing carrier, vendor, or external partner relationships in a healthcare, insurance, or financial services environment.
• Understanding of high-cost claims, funding arrangements, reimbursement processes, audit requirements, and operational risk management.
• Experience standing up new governance models, relationship management functions, escalation frameworks, or centralized ownership structures.
• Experience working across finance, legal, compliance, operations, claims, account management, underwriting, and executive leadership teams.
• Ability to influence without direct authority and drive alignment across stakeholders with differing priorities.
• Strong executive presence with the ability to simplify complex issues and recommend practical, business-oriented solutions.
• Experience developing KPIs, dashboards, operating routines, and performance management tools.

Education

Bachelor's degree preferred or equivalent combination of education, specialized training, and relevant professional experience.

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.