Claims Operations Director

🕒 January 5

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $137.2k - $174.9k / year

⏰ Full Time

🔴 Lead

⚙️ Operations

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UNITE HERE HEALTH

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

UNITE HERE HEALTH is a national health fund that collaborates with local unions and employers to provide health benefits and resources aimed at improving the health and healthcare of its participants. Serving approximately 200,000 children and adults nationwide, UNITE HERE HEALTH focuses on offering high-quality, affordable healthcare solutions and aims for better service through innovation and participant engagement.

📋 Description

• 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 above industry benchmarks through consistent system configurations and scalable operational strategies. • 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 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 develop and enforce operational policies, procedures, and utilization safeguards. • Coach and develop managers and supervisors for future leadership roles.

🎯 Requirements

• 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. • Experience with Taft-Hartley plan administration strongly preferred. • The ability to travel 15+% as needed.

🏖️ Benefits

• Medical • Dental • Vision • Paid Time-Off (PTO) • Paid Holidays • 401(k) • Short- & Long-term Disability • Pension • Life • AD&D • Flexible Spending Accounts (healthcare & dependent care) • Commuter Transit • Tuition Assistance • Employee Assistance Program (EAP)