Director of Claims Cost Management

Join to apply for the Director of Claims Cost Management role at UNITE HERE HEALTH

This range is provided by UNITE HERE HEALTH. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$/yr - $/yr

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.

We’re looking for a strategic leader to shape and drive our Claims Cost Management (CCM) Program
—a critical initiative focused on payment integrity, reimbursement accuracy, and analytics-driven insights. As Director of Claims Cost Management
, you’ll set the vision, lead execution, and ensure claims are paid correctly the first time, reducing unnecessary medical spending in a transparent, cost‑efficient way.

This role blends strategy, operations, and analytics. You’ll partner across Claims, Medical Cost Management, Managed Care Vendor Administration, IT, Finance, and external vendors to design and sustain programs that optimize reimbursement, strengthen coding and billing accuracy, and turn emerging claim trends into actionable insights. You’ll be the central connector ensuring CCM initiatives align with Fund policies, regulatory requirements, and organizational goals.

• Build and lead a comprehensive CCM strategy, leveraging internal tools and external vendors.
• Oversee programs for claim editing, coding validation, anomaly detection, and payment accuracy.
• Collaborate with network partners to ensure reimbursement integrity and address emerging billing trends.
• Integrate claims insights into prior authorization and early intervention strategies.
• Develop dashboards, cost‑savings reports, predictive analyses, and financial impact assessments for leadership and Trustees.
• Identify inappropriate claim submissions and translate findings into actionable recommendations.
• Drive initiatives that improve billing accuracy, reduce rework, and promote high‑value care.
• Lead cost‑management pilots, system enhancements, and vendor‑supported programs.
• Ensure compliance with national standards, audit expectations, and Fund policies.
• Manage CCM vendor relationships and performance in partnership with MCVA.
• Foster a culture of continuous improvement, accountability, and innovation.

• Experience:
  
  10+ years in claims operations, payment integrity, or cost management with measurable financial impact; 5–7 years in leadership roles.
• Expertise:
  Claims adjudication, reimbursement methodologies, payment accuracy programs; establish goals and achieve measurable results; operational lead for cost‑management pilots, system enhancements, and vendor‑supported programs.
• Education:
  
  Bachelor’s degree or equivalent experience; coding certification preferred.
• Skills:
  
  Strategic and financial acumen, data‑driven decision‑making, program/project management, advanced Excel and claims editing systems, preparation and presentation of reports, analytic dashboards and recommendations, policy development and coordination.
• Knowledge:
  Regulatory, compliance, audit requirements, vendor performance evaluation and outcome monitoring.
• Leadership:
  Proven ability to influence senior stakeholders and lead cross‑functional initiatives.
• Travel: 15–25%.

Salary range for this position: $137,200 – $174,900. Actual base salary may vary based upon 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.

Monday–Friday, 7.5 hours per day (37.5 hours per week) as a remote employee with 15%–25% travel.

• Medical, Dental, Vision
• Paid Time‑Off (PTO) & Paid Holidays
• 401(k) with company match
• Short‑ and Long‑term Disability
• Pension
• Life, AD&D
• Flexible Spending Accounts (healthcare & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)