Director of Claims Operations

Job Description

Job Description

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The Director of Claims Operations provides strategic and operational leadership across all aspects of the organization’s claims functions. This role ensures alignment with the organization’s mission and performance goals, driving excellence in claims adjudication, appeals, and customer service. With a focus on continuous improvement, the Director develops scalable solutions that support both current operations and long-term business growth. This leader plays a critical role in enhancing the member experience by ensuring claims are processed accurately, efficiently, and with the highest quality standards.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Lead and manage all claims-related functions, including electronic claim intake, mail distribution, document imaging, data entry, provider maintenance, quality assurance, and training.
• 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.
• Standardize benefit codes and exceptions and develop master category definitions for use across all plan units.
• Collaborate with IT and network vendors to ensure electronic claim files comply with HIPAA standards and regulatory changes, including the No Surprises Act.
• Define analytical requirements for claims-related reports, KPIs, and metrics within the enterprise data warehouse.
• Establish and execute short- and long-term strategic goals for claims processing efficiency and effectiveness.
• Lead growth initiatives for the claims function, including due diligence, plan integration, staffing, and systems.
• Ensure timely and accurate adjudication and payment of hospital, physician, disability, life, and supplementary claims.
• Partner with Regional Directors and Trustees to improve medical appeals efficiency and transparency.
• Propose benefit changes based on claims and appeals trends to reduce member abrasion.
• Oversee Short-Term Disability claims in compliance with Department of Labor and Fund guidelines.
• Manage RFP processes for claims vendors and ensure timely resolution of customer service inquiries.
• Implement system changes to support new plan units, benefit updates, vendor transitions, and legislative requirements, as well as to recommend system upgrades.
• Develop and enforce operational policies, procedures, and utilization safeguards.
• Monitor performance metrics and lead training and development initiatives.
• Prepare management reports and conduct claims studies to inform strategic decisions and partner with service areas ensuring claims accuracy and understanding.
• Authorize exceptions to standard operating procedures and manage departmental budgets.
• Collaborate cross-functionally to align claims processing policies with organizational goals.
• Coach and develop managers and supervisors for future leadership roles.
• Lead HR functions including hiring, performance evaluation, and employee development.
• Analyze problems, develop solutions, and implement recommendations.
• Exemplifies the Fund’s values in leading and fostering a respectful, trusting, and engaged culture of inclusion and engagement

ESSENTIAL QUALIFICATIONS

Salary range for this position : Salary $137,200 - $174,900. Actual base salary may vary based upon, but not limited to : relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs) : Monday~Friday, 7.5 hours per day (37.5 hours per week) as a hybrid employee with 15% - 25% travel requirements.

We reward great work with great benefits, including but not limited to : 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, and Employee Assistance Program (EAP).

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