Process Consultant, Stop Loss Claims

Jobtailor; United States; On-site; USD 110,000 - 150,000; Full time

Job summary

Jobtailor seeks a governance-focused professional to lead end-to-end Stop-Loss Claims process documentation and controls. You will standardize SOPs, templates, and workflows, act as the process SME in audits and regulatory reviews, and advise leadership on risks and remediation strategies.

The role requires strong analytical skills, experience with cross-functional improvement, and familiarity with AI-enabled document processing and analytics.

Qualifications

• 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.
• 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 emerging technologies and AI-enabled solutions, including intelligent document processing, workflow automation, and predictive analytics.
• Familiarity with process mapping and documentation platforms such as Visio, Miro, and enterprise knowledge repositories.
• Lean, Six Sigma, or comparable continuous improvement training
• Experience supporting large-scale change management or operational readiness efforts

Responsibilities

• Support the end-to-end governance framework for Stop-Loss Claims processes, SOPs, templates, and workflows
• Establish standards for documentation quality, structure, version control, approval, and lifecycle management
• Ensure documentation remains audit-ready and aligned with regulatory requirements, system capabilities, and business strategy
• Serve as a primary process SME during internal and external audits, regulatory reviews, and risk assessments
• Advise leaders on process controls, documentation risk, and remediation strategies
• Lead cross-functional process evaluations to identify inefficiencies, control gaps, and variation
• Design and implement standardized, scalable process solutions to improve accuracy, throughput, and operational resilience
• Analyze audit findings, QA trends, operational metrics, and error patterns to inform improvement roadmaps
• Liaise across Claims Operations, QA, Compliance, Audit, Legal, IT, and Learning & Development
• Define business requirements, document future-state workflows, and ensure operational readiness for system and technology initiatives
• Partner with Learning & Development on training strategy and materials
• Lead change planning, communication, adoption strategies, and implementation guidance
• Coach leaders and teams through change and ensure adoption of revised processes
• Identify process-driven risks and recommend mitigation strategies
• Drive corrective and preventive actions through procedure, control, and guidance updates
• Strengthen the Claims control environment through clarity, consistency, and accountability

Skills

Stop-Loss Adjudication

Process Documentation

Cross-Functional Improvement

Change Management

Data Analysis

Executive Communication

Regulatory Awareness

Education

Lean Six Sigma Certification

Tools

Visio

Miro

Intelligent Document Processing

Workflow Automation

Predictive Analytics

Job description

• Support the end-to-end governance framework for Stop-Loss Claims processes, SOPs, templates, and workflows
• Establish standards for documentation quality, structure, version control, approval, and lifecycle management
• Ensure documentation remains audit-ready and aligned with regulatory requirements, system capabilities, and business strategy
• Serve as a primary process SME during internal and external audits, regulatory reviews, and risk assessments
• Advise leaders on process controls, documentation risk, and remediation strategies
• Lead cross-functional process evaluations to identify inefficiencies, control gaps, and variation
• Design and implement standardized, scalable process solutions to improve accuracy, throughput, and operational resilience
• Analyze audit findings, QA trends, operational metrics, and error patterns to inform improvement roadmaps
• Liaise across Claims Operations, QA, Compliance, Audit, Legal, IT, and Learning & Development
• Define business requirements, document future-state workflows, and ensure operational readiness for system and technology initiatives
• Partner with Learning & Development on training strategy and materials
• Lead change planning, communication, adoption strategies, and implementation guidance
• Coach leaders and teams through change and ensure adoption of revised processes
• Identify process-driven risks and recommend mitigation strategies
• Drive corrective and preventive actions through procedure, control, and guidance updates
• Strengthen the Claims control environment through clarity, consistency, and accountability

Requirements

• 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
• 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 emerging technologies and AI-enabled solutions, including intelligent document processing, workflow automation, and predictive analytics
• Familiarity with process mapping and documentation platforms such as Visio, Miro, and enterprise knowledge repositories
• Lean, Six Sigma, or comparable continuous improvement training
• Experience supporting large-scale change management or operational readiness efforts

Core Competencies

Demonstrates expertise in Stop-Loss Claims processes, operational workflows, and regulatory compliance, with a strong focus on process documentation and improvement. Proven ability to lead cross-functional initiatives and drive change management strategies effectively.

Highest-signal resume keywords

• Stop-Loss Adjudication
• Process Documentation Governance
• Cross-Functional Process Improvement
• Change Management
• Lean Six Sigma Training

ATS Optimization Keywords

Hard Skills

• Process Mapping
• Operational Workflows
• Regulatory Compliance
• Analytical Skills
• Problem-Solving Skills

Soft Skills

• Written Communication
• Verbal Communication
• Coaching Skills

Certifications & Qualifications

• Lean Six Sigma Certification

Industry Keywords

• Stop-Loss Claims
• Claims Operations
• Audit
• Compliance
• Risk Management

Tools & Technologies

• Visio
• Miro
• Intelligent Document Processing
• Workflow Automation
• Predictive Analytics