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UNITE HERE HEALTH · 5 hours ago

Claims Operations Director

Oak Brook, IL

Full-time

Hybrid

Director/Executive

$137K/yr - $175K/yr

15+ years exp

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. They are seeking a seasoned, strategic leader to oversee and optimize their Claims Operations function, focusing on driving efficiency, innovation, and long-term growth in claims processing.

ConsultingHealth CareHospitalNon Profit

Comp. & Benefits

Hiring Manager

Lori Yunk

Responsibilities

Establish and execute short- and long-term strategic goals for claims processing efficiency and effectiveness

Drive continuous improvement initiatives and foster a culture of innovation

Lead growth initiatives for the claims function, including due diligence, plan integration, staffing, and systems

Collaborate cross-functionally to align claims processing policies with organizational goals

Lead and manage all claims-related functions, including: Electronic claim intake, mail distribution, document imaging, data entry, provider maintenance, quality assurance, and training

Ensure timely and accurate adjudication and payment of hospital, physician, disability, life, and supplementary claims

Oversee Short-Term Disability claims in compliance with Department of Labor and Fund guidelines

Partner with Regional Directors and Trustees to improve medical appeals efficiency and transparency

Oversee system configuration projects related to benefit plan design, code maintenance, claims editing software, network/vendor mandates, and Fund-wide initiatives

Drive auto-adjudication rates (we’re currently at 75%) above industry benchmarks through consistent system configurations and scalable operational strategies

Standardize benefit codes and exceptions and develop master category definitions for use across all plan units

Implement system changes to support new plan units, benefit updates, vendor transitions, and legislative requirements, as well as recommend system upgrades

Define analytical requirements for claims-related reports, KPIs, and metrics within the enterprise data warehouse

Monitor performance metrics and prepare management reports

Conduct claims studies to inform strategic decisions and partner with service areas ensuring claims accuracy and understanding

Propose benefit changes based on claims and appeals trends to reduce member abrasion

Collaborate with IT and network vendors to ensure electronic claim files comply with HIPAA standards and regulatory changes, including the No Surprises Act

Develop and enforce operational policies, procedures, and utilization safeguards

Manage RFP processes for claims vendors and ensures timely resolution of customer service inquiries

Implement cost management strategies and fiscal risk mitigation practices

Authorize exceptions to standard operating procedures and manage departmental budgets

Coach and develop managers and supervisors for future leadership roles

Lead HR functions including hiring, performance evaluation, and employee development

Exemplify the organization’s values in fostering a respectful, trusting, and engaged culture of inclusion

Qualification

Claims processing expertiseSystem configurationLeadership experienceData analyticsCompliance knowledgeOperational policiesCoachingDevelopmentCost management strategiesTeam managementCross-functional collaboration

Required

Minimum 15 years of progressive leadership experience in automated group health claims environments, preferably within organizations of 300+ employees

At least 10 years of team management experience, including 5+ years in senior leadership roles

5+ years of experience in system configuration and benefit plan design

Bachelor's degree in business administration, healthcare, or related field preferred (or equivalent experience required)

Deep knowledge of group health benefits and claims processing systems

Familiarity with DOL, ERISA, ACA, and other regulatory requirements related to group health plan administration

The ability to travel 15+% as needed