[Remote] Sr. Director Claims Operations

Note: The job is a remote job and is open to candidates in USA. UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. They are seeking a strategic leader for Claims Operations who will enhance claims processes and optimize cost structures while driving innovation and operational excellence. 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 Skills • 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 • Experience with Taft-Hartley plan administration strongly preferred 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) Company Overview • Unite Here Health is a non-profit organization that provides health benefits and healthcare services. It was founded in undefined, and is headquartered in Oak Brook, Illinois, USA, with a workforce of 501-1000 employees. Its website is https://www.uhh.org/. Apply To This Job