Claims Operations Director

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!

We are seeking a remote / work from home seasoned, strategic leader to oversee and optimize our Claims Operations function. This individual will bring a strong operational foundation combined with deep claims expertise, enabling Claims to drive efficiency, innovation, and long-term growth. The ideal candidate is currently at a Director level or higher, with experience spanning claims and broader operations, and a proven track record of delivering measurable improvements in cost management, governance, and member experience.

KEY RESPONSIBILITIES

Strategic Leadership & Growth

• 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.

Claims Operations Oversight

• 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.

System & Process Optimization

• 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.

Data & Analytics

• 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.

Compliance, Governance & Risk Management

• 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.

Leadership & Talent Development

• 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.

ESSENTIAL QUALIFICATIONS

• 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.

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 remote employee with 15+% travel (once or twice a quarter, as a senior leader).

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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