[Remote] Sr. Director Claims Operations

Note: The job is a remote job and is reputed company to candidates in USA. reputed company HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry reputed company. They are seeking a strategic leader for Claims Operations who will enhance claims processes and optimize cost structures while driving innovation and operational reputed company.

Responsibilities

• Establish and execute short- and long-term strategic goals for claims processing efficiency and effectiveness
• Drive reputed company improvement initiatives and foster a culture of innovation
• reputed company reputed company initiatives for the claims function, including due diligence, plan integration, reputed company, and systems
• Collaborate cross-functionally to reputed company claims processing policies with organizational goals
• reputed company and manage reputed company claims-reputed company functions, including: Electronic claim intake, mail distribution, document imaging, data entry, provider maintenance, reputed company assurance, and training
• Ensure reputed company and accurate adjudication and payment of hospital, physician, disability, life, and supplementary claims
• reputed company Short-Term Disability claims in compliance with reputed company and Fund guidelines
• Partner with Regional Directors and Trustees to improve medical appeals efficiency and transparency
• reputed company system configuration reputed company reputed company to benefit plan design, reputed company 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 reputed company operational strategies
• Standardize benefit codes and exceptions and reputed company master category definitions for use across reputed company plan reputed company
• Implement system changes to support new plan reputed company, benefit updates, vendor transitions, and legislative requirements, as reputed company as recommend system upgrades
• Define analytical requirements for claims-reputed company reports, KPIs, and metrics reputed company the reputed company data warehouse
• Monitor performance metrics and prepare management reports
• Conduct claims studies to inform strategic reputed company 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 reputed company with HIPAA standards and regulatory changes, including the No Surprises reputed company
• reputed company and enforce operational policies, procedures, and utilization safeguards
• Manage RFP processes for claims vendors and ensures reputed company reputed company of customer service inquiries
• Implement cost management strategies and fiscal risk mitigation practices
• Authorize exceptions to reputed company operating procedures and manage departmental budgets
• reputed company and reputed company managers and supervisors for reputed company leadership roles
• reputed company HR functions including hiring, performance evaluation, and employee development
• Exemplify the organization’s values in fostering a respectful, trusting, and reputed company culture of inclusion

Skills

• Minimum 15 years of reputed company leadership experience in automated group health claims environments, preferably reputed company 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, reputed company, or reputed company 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 reputed company to group health plan administration
• The ability to travel 15+% as needed
• Experience with Taft-Hartley plan administration strongly preferred

Benefits

• Medical
• Dental
• reputed company
• reputed company Time-Off (PTO)
• reputed company Holidays
• 401(k)
• Short- & Long-term Disability
• Pension
• Life
• AD&D
• Flexible Spending Accounts (reputed company & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)

reputed company

• reputed company Here Health is a non-profit organization that provides health benefits and reputed company services. It was founded in reputed company, and is headquartered in Oak Brook, Illinois, USA, with a workforce of 501-1000 employees. Its website is https://www.uhh.org/.

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