UNITE HERE HEALTH

Oversee and optimize claims operations, drive system and process improvements, and ensure compliance and governance. | Extensive leadership experience in claims or healthcare operations, system configuration expertise, and regulatory knowledge. | 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).

Analyze and improve healthcare data quality, develop audits and reports, and mentor analysts on data integrity. | 10+ years healthcare data and SQL experience, bachelor’s degree in related field, knowledge of medical codes, and experience with Power BI or Tableau. | 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 Sr. Data Quality Engineer II assists the Manager, and various departments, with their data quality/data integrity needs across medical, pharmacy, claims, eligibility and external data. They closely understand business needs, review and drive improvements, as well as create and enhance reports used to monitor data quality and data integrity. The Sr Data Quality Engineer II will be a primary user of the organization’s data warehouse, as well as various internal information systems. This individual will also mentor other analysts in defining methodologies and coding to improve efficiency and accuracy. ESSENTIAL JOB FUNCTIONS AND DUTIES • Collects, compiles, and analyzes data to measure and report on data quality issues and data monitoring • Proactively evaluates and improves the quality of the data used to measure and report on plan, provider, and program performance • Comparative and root cause analysis to identify and understand Data Quality issues • Develops check and audit protocol of various data sources to ensure reporting data is accurate and complete, and refines efficient workflows for vetting and resolving data integrity concerns • Works with business partners and members of other departments to assist with data quality checks prior to reports being delivered • Develops and automates standard periodic audits to identify known and high-impact issues • Identifies, develops, and implements methods for improving reporting efficiency, automating data audit processes, and improving data quality and reporting • Works with and mentors’ other analysts to perform a variety of ad-hoc analysis and reports as requested around data quality and data integrity • Maintains and applies knowledge of current trends, practices, and developments in healthcare data quality • Exemplifies the Fund’s values in leading and fostering a respectful, trusting, and engaged culture of inclusion and engagement ESSENTIAL QUALIFICATIONS • 10+ years of experience in healthcare and claims data analysis (medical, pharmacy, eligibility); ETL experience and data quality audit experience preferred • 10+ years of experience with SQL programming • Bachelor’s degree in healthcare, Informatics, Computer Science, Economics, or related field or equivalent work experience required (Master’s degree preferred) • Working knowledge of and experience with industry-standard medical codes such as revenue codes, ICD10 classifications, CPT codes, etc. • Experience with Power BI or Tableau report development including visualizations, dataset building, and report authoring Salary range for this position: Salary $113,600 - $142,000. 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) fully remote employee. 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). #LI-Remote