UNITE HERE HEALTH

Role Description The Claims Adjudicator II position will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries. - Screens claims for completeness of necessary information - Verifies participant/dependent eligibility - Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents - Codes basic information and selects codes to determine payment liability amount - Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered - Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers - Handles the end to end process of Medicare Secondary Payer (MSP) files - Processes Personal Injury Protection (PIP) claims - Requests overpayment refunds, maintains corresponding files and performs follow-up actions - Handles verbal and written inquiries received from internal and external customers - Processes Short Term Disability claims - Adjudicates claims according to established productivity and quality goals - Achieve individual established goals in order to meet or exceed departmental metrics Qualifications - 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment - Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits - Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and its related processes - Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes - Fluency (speak and write) in Spanish, preferred Requirements - Salary range for this position: Hourly $20.36 - $24.97 - 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, after 1-week training onsite in Oak Brook, IL. (Travel and Lodging paid for by UHH) Benefits - Medical - Dental - Vision - Paid Time-Off (PTO) - Paid Holidays - 401(k) - Pension - Short- & Long-term Disability - Life - AD&D - Flexible Spending Accounts (healthcare & dependent care) - Commuter Transit - Tuition Assistance - Employee Assistance Program (EAP)

Role Description We are seeking a forward-thinking, systems-savvy Claims Operations strategic leader to join our exceptionally strong, long-tenured, and deeply experienced team. This leader will introduce new ways of thinking that expand our decision-making lens and challenge long-standing assumptions in the best possible way. This remote/work-from-home role is designed for a dynamic professional with a proven record of enhancing mature claims operations and optimizing cost structures by infusing cutting-edge ideas and methods that elevate how we evaluate, decide, and execute. As a trusted business partner, this leader will help us question the familiar, surface unseen opportunities, and push our organization toward a more modern, creative, insight-driven future. Currently operating at Director level or higher, the successful candidate will unlock new pathways for operational excellence by translating data into creative solutioning and applying their unique outside perspective to elevate our approach to problem-solving. The ideal candidate excels in leveraging data and digital tools, always seeking opportunities to strengthen workflows and governance, and to elevate the member experience by delivering greater efficiency and measurable business impact at scale. Qualifications - 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. Requirements - 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 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. 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)

Role Description The purpose of this role is to own and drive the Fund’s talent acquisition strategy and execution, attracting, selecting, and hiring top talent aligned with our mission, culture, and long-term goals. This role leads full-cycle recruiting while building and optimizing scalable processes, shaping the Employee Value Proposition, and ensuring a high-quality candidate experience. As a sole contributor, this position is accountable for end-to-end recruiting outcomes, partnering closely with hiring managers and senior leadership to align workforce needs with effective hiring strategies. The role requires strong full-cycle recruiting expertise, strategic thinking, and the ability to translate business priorities into actionable talent plans while leveraging technology and data to improve results. Essential Job Functions and Duties - Perform full-cycle recruiting including needs intake, sourcing, screening, scheduling, selection, hiring and parts of onboarding. - Develop and maintain a strong understanding of Fund culture and values to effectively qualify candidates and adhere to our commitment to the recruitment of a diverse workforce. - Devise, implement, maintain and update sourcing strategies, including employer branding, to build pipelines and compete effectively in the marketplace as a Taft-Hartley, non-profit. - Modify and maintain end-to-end hiring processes to ensure an excellent candidate and team member experience. - Build and maintain strong relationships with hiring managers, using clear and tailored communication, educating on best practices, and demonstrating flexibility and active listening to ensure individual, team, and organizational needs are met. - Provide complete, accurate information to candidates about the Fund and position; manage and coordinate all TA process communications with candidates, including scheduling and logistics, to create an overall positive candidate experience. - Build and maintain strong relationships with HR peers; collaborate with HR team members throughout the recruiting and onboarding processes. - Develop and maintain strong relationships with vendors and agency partners to ensure tools, services, and support are delivered with quality and are in line with our fiscal responsibilities. - Own and leverage technology, tools and services in support of effective recruitment including applicant tracking systems, job boards, screening tools, and reporting and metrics tools. - Maintain accurate records, collect and report key data and KPIs, and organize and file key materials including interview notes, scorecards, and related paperwork. - Ensure compliance with Fund policy, applicable regulatory guidelines and requirements, and changes in legal guidance. - Contribute to the broader HR strategy, remains informed on HR and Fund priorities, and participates in projects to improve team member experience. - Ensure that staffing needs are being met with a long-term strategy in mind. - Coordinate with hiring managers to identify staffing needs and candidate selection criteria. - Organize and attend job fairs and recruitment events to build a strong candidate pipeline as needed. - Collaborate with the hiring manager, HRBP and HR Compensation during the offer recommendation process. - Post jobs on various platforms including but not limited to ADP, LinkedIn, and Indeed. - Set goals and achieve measurable results. - Contribute ideas to plans and achieving department goals. - Exemplify the Fund’s BETTER Values and professional effectiveness dimensions in contributing to a respectful, trusting, and engaged culture of diversity and inclusion. - Perform other duties as assigned within the scope of responsibilities and requirements of the job. - Perform Essential Job Functions and Duties with or without reasonable accommodation. Qualifications - 3 ~ 5 years of direct talent acquisition experience minimum. - Experience in full-cycle recruiting, using various interview techniques and evaluation methods. - Proficiency in social media, resume databases, and professional networks. - Proficiency in documenting processes and keeping up with industry trends. - Working knowledge and experience in applicant tracking systems (ADP). - Bachelor's Degree or equivalent work experience required. - Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook). - Intermediate level Microsoft Excel skills. - Intermediate level HRIS system skills. - 10% ~ 15% travel to job fairs. - Excellent interpersonal and communication skills. - Good negotiation skills. - Proactive and independent with the ability to take initiative. - Excellent time management skills with proven ability to meet deadlines. - Familiarity with laws, regulations, and best practices applicable to hiring and recruitment. - Effectively manages competing deadlines and multiple projects. Salary and Work Schedule - Salary range for this position: $85,300 ~ $106,700. - Work Schedule (may vary to meet business needs): Monday ~ Friday, 7.5 hours per day (37.5 hours per week). Benefits - Medical, Dental, Vision. - Paid Time-Off (PTO), Paid Holidays. - 401(k), Pension. - Short- & Long-term Disability. - Life, AD&D. - Flexible Spending Accounts (healthcare & dependent care). - Commuter Transit. - Tuition Assistance. - Employee Assistance Program (EAP).