• Director of Claims

    Job Locations US-IL-Aurora
    Posted Date 2 months ago(10/4/2018 9:48 PM)
    # of Openings
  • Overview




    Looking for a way to influence the health and healthcare of many?


    If so, we’d love to hear from you! Our mission-driven organization is focused on theTriple Aim - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.


    UNITE HERE HEALTH serves 90,000+ workers 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!



    Key Attributes:

    • Integrity – Must be trustworthy and principled when faced with complex situations
    • Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required
    • Communication – Ability to generate concise, compelling, objective and data-driven reports
    • Teamwork – Working well with others is required in the Fund’s collaborative environment
    • Diversity – Must be capable of working in a culturally diverse environment
    • Continuous Learning – Must be open to learning and skill development. As the Fund’s needs evolve, must be proactive about developing new areas of expertise
    • Lives our Values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect)



    The Director of Claims provides managerial leadership to all aspects of Claims Operations to include, but not limited to: alignment with organizationsl strategic direction, developing longer-term strategic and annual operating business plans, achieving all performance metrics and goals, ensuring continuous improvement of the timeliness, accuracy, and quality of claims processing; coaching and developing the team and future leaders, and developing and managing the Claims budget.   


    Job functions Include: 

    • Sets short and long-term strategic and operational goals for an effective and efficient claims processing function
    • Develops and manages growth-related plans and activities for the Claims function, including due diligence, plan integration, personnel, systems, etc.
    • Recommends system changes/upgrades to the core claims processing system
    • Plans, directs and manages the cost effective, timely and accurate processing/adjudication and payment of hospital, physician, disability, life, and/or supplementary claims
    • Directs and manages functions in support of claim adjudication, including electronic claim acquisition, mail receipt and distribution, document imaging, keying operations, provider maintenance, quality assurance, training, plan building and code maintenance, and automated claim review processes
    • Directs and manages the timely processing of customer service inquiries from other Fund departments and offices
    • Plans, directs, and implements, necessary system changes to support the addition of new plan units, changes in benefits for existing plan units, changes in vendors, claim system version updates, and legislated requirements
    • Directs the development and implementation of routine operating plans, policies, procedures, and utilization safeguards
    • Develops, maintains, and monitors performance measures and goals, as well as related training and development
    • Directs the preparation of management reports and the completion of claims studies
    • Determines and authorizes exceptions to normal operating procedures
    • Plans, prepares, and monitors the operating budget for operational effectiveness
    • Interacts and works with other management personnel across the organization in a collaborative team approach to resolve issues and ensure processing policies, guidelines, etc. are consistent with strategic goals of the organization.
    • Coaches and develops managers and supervisors for the next level of leadership opportunities
    • Provides assistance and partners with service areas to insure accuracy and clear understanding of how claims are paid
    • Manages the Human Resources component
    • Performs other duties as assigned within the scope of responsibilities and requirements of the job
    • Performs Essential Job Functions and Duties with or without reasonable accommodation


    • Bachelor's Degree in Business Administration, Healthcare or related field or equivalent work experience required
    • Master’s Degree in Business Administration, Healthcare or related field preferred
    • 10+ years of direct experience gained in increasingly responsible management positions within an automated group health claims environment with multiple plans and networks and varying degrees of benefits
    • 5 ~ 7 years of team management experience required, of which 3+ are in a senior leadership position
    • Working knowledge and experience in Group health benefits and claim processing systems functions and expectations
    • Understanding of claims pricing methodologies and the pros and cons of each.
    • Familiar with Department of Labor (DOL), Employee Retirement Income Security Act (ERISA), Affordable Care Act (ACA) and regulatory compliance requirements associated with Group Health Plan benefit administration
    • Taft Hartley plan administration background preferred



    • Advanced level Microsoft Office skills (PowerPoint, Word, Outlook)
    • Advanced level Microsoft Excel skills
    • Preferred fluency (speak and write) in Spanish
    • 10% ~ 15% travel
    • Innovation
    • Project management
    • Be driven by and demonstrate leadership qualities that reflect the Fund’s mission, vision, and values
    • Gather business priorities and develop clear strategic plans based on them
    • Translate strategic plans into operational plans that management and staff can quickly understand and successfully execute
    • Analyze and interpret financial data, identify trends, provide analysis and reporting with options, recommendations, and mitigation plans.
    • Work collaboratively with all levels of management and staff
    • Lead others to collaborate and achieve results in a team-oriented environment
    • Problem-solve, multi-task, and identify effective and innovative process improvements and cost-saving measures
    • Be detail-oriented with the capability to quickly research, analyze, and interpret data
    • Monitor and validate all HIPAA requirements and standards are accounted for and appropriate and reasonable PHI security is in place throughout the claims processing workflow
    • Manage competing deadlines and multiple projects in a fast-paced environment
    • Coaching, counseling, developing, mentoring, and providing regular constructive feedback to staff/teams to improve productivity, individual/team performance, and organizational consistency/stability



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