[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