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Unite Here jobs - 22 jobs

  • Claims Supervisor

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    UNITE HERE HEALTH serves 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 Claims Supervisor will oversee the claims production team who is scanning, uploading and keying in UNITE HERE HEALTH's member's and dependent's medical, vision, dental and short-term disability claims related correspondence. This position is responsible for the accuracy and timeliness of handling of claims and member correspondence based on the guidelines set forth by the Department of Labor. The Claims Supervisor is responsible for partnering with internal and external parties to ensure that the turnaround times are met, which includes, but is not limited to the BlueCross and BlueShield incentive. This position is relied upon as a subject matter expert for creating and updating provider records, Coordination of Benefits provisions and eligibility-related inquiries within the Department; this includes providing support to the Legal Team as it relates to subrogation files. The Claims Supervisor supports the production team through functions in collaboration and coordination with other teams, including New Membership, Member Services and C&E teams. To provide daily support to the Claims Department through updates to members COB information and providers records in the claims processing system. This position provides development, training, and coaching to employees for guidance and direction to ensure that a high level of accountability and performance is delivered to our participants. ESSENTIAL JOB FUNCTIONS AND DUTIES * Provides leadership, motivates, advocates, coaches and develops team performance and promotes Fund culture/mission along with advocating for appropriate change with a positive attitude * Holds direct reports accountable for individual performance, which may result in disciplinary action * Promotes operational efficiency and quality by critically analyzing team processes with the intention of improving member experience and creating a high level of consistency in the team's quality and production results. * Manages and reports on team inventory to ensure that departmental metrics are met * Successfully investigates and responds to escalated inquiries from internal and external sources * Allocates and cross trains team resources to complete goals * Assists in training to other UHH operational areas * Collaborates and partners with other Claims Department Supervisors to ensure consistency in processing across all teams and to identify ways to be BETTER, more efficient, adaptable and participant focused * Ensures adherence to policies and procedures are consistently applied * Assists in the design and preparation of management reports * Collaborates with the Legal team to understand legal regulations and plan provisions * Demonstrates necessary competence in technical, industry standard and soft skills to effectively support and develop staff * Communicates with Executive Leadership through creation of the monthly Claims Department Dashboard. * Interacts with members and UHH operational areas to resolve complex issues * Interacts with members and UHH operational areas to educate regarding policies and procedures * Strictly adheres to all regulatory and legal requirements, including time deadlines * Ensures members Coordination of Benefits information is accurately and consistently updated and maintained * Oversees the creation and maintenance of provider records for accuracy and claim payments, as well as, annual 1099 reporting to IRS * Demonstrates personal accountability for personal actions as well as team and departmental results through ensuring claims and correspondence are handled in accordance with the guidelines set forth by the DOL and our internal Claims Policy Committee * Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints * Supervises, leads, and delegates work and coaches, mentors, develops employees * Analyzes problems, identifies and develops alternative solutions, projects consequences of proposed actions and implements recommendation/solutions * Recommends hires and promotions, directs and evaluates employment decisions for all assigned positions * Assists with developing and coordinating policies and procedures * Responsible for the oversight of continued employee training requirements, safety and quality initiatives ESSENTIAL QUALIFICATIONS: * Bachelor's degree in related field or equivalent work experience required * 4 ~ 6 years of direct experience minimum * 3 ~ 5 years of supervisory experience required * Preferred fluency (speak and write) in Spanish * Intermediate level Microsoft Office and Excel skills * Professional level training that provides working knowledge of: * Administration of welfare plan benefits * High degree of Claims Processing Knowledge * Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA * Audit and billing procedures * Plan documents and summary plan descriptions * Vendor relations * Eligibility rules Salary range for this position: Salary $70,500- $88,200. 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: Monday~Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid (mostly work from home) opportunity with quarterly (approx.) in-office time. 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 #LI-LY-3
    $70.5k-88.2k yearly Auto-Apply 5d ago
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  • VP of Network Strategy & Market Development

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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 Vice President of Network Strategy & Market Development is a senior executive leader responsible for designing, executing, and optimizing Aurora's managed care plan and provider network and market management strategy. This role provides strategic and operational leadership to the Fund's Aurora staff and oversee network contracting, provider partnerships, vendor management, and market development to ensure the organization delivers competitive, high-quality, cost-effective care solutions across Aurora's regions/markets. This position is a key contributor to the overall performance of the Aurora-based Plan. This role will provide overall strategic guidance to the Aurora Plan Units, leading the development of a comprehensive network strategy-including contracting with managed care plans, direct contracts with hospital systems, provider groups, and ancillary service providers to strengthen our Aurora plan performance on cost and position the organization for increased growth. This position directs the negotiation and management of health plan, provider, and other vendor agreements, cultivates strategic partnerships with health systems, key physician groups, and other strategic market partners, and ensures strong operational performance of contracted vendors/providers. The leader also oversees vendor selection and performance to support network adequacy, access, and service delivery. Working closely with executive leadership, the VP analyzes market trends, competitive dynamics, and regulatory changes to identify opportunities for expansion and differentiation. The role is accountable for vendor and market performance metrics, total cost of care initiatives as it relates to contracting, and market-level business results related to our contracts. This position requires strong strategic vision, deep managed care expertise, cross-functional collaboration, and the ability to influence both internal and external stakeholders. Key Functions Include: Vendor Management The Vice President will oversee a vendor management team (MCVA) to ensure that upon the closure of critical deals with vendors, all onboarding and implementation issues are addressed, and performance is monitored closely to extract full value from vendor partnerships. Under the direction of the Vice President, the MCVA Team will support final negotiations; coordinate with internal and external stakeholders to implement contracts; and manage day-to-day contractual relationships with a wide range of managed care partners (contracted network carriers, vendors and preferred providers). Network Contracting Strategy and Execution The Vice President will oversee the network contracting strategy and execution team and provide expert guidance in the design, negotiation and execution of advanced contracting models and cultivation of key provider partnerships. They will ensure UHH's contracting strategy is centered around improving affordability, quality and overall network performance. The Vice President will drive innovation in UHH's contracting strategy, including the exploration of opportunities to increase quality and decrease costs through both standard and novel arrangements with third party administrators, direct contracts with providers, value-based contracts, carve outs, point solutions and other approaches that deliver value. Market Development The Vice President will provide oversight to the team to build a deep understanding of major UHH markets (Chicago, NYC, Boston, AC, national Food Service Plan) and provide clear guidance on where to invest, intervene or innovate. They will guide the examination of key trends, market dynamics, local legislation and policy activity, and union and employer points of view to anticipate future impacts and translate intelligence into actionable, market-specific strategies that increase quality, decrease costs and deliver positive member experience. The Vice President will work in close collaboration with peers, including the Aurora Plan Units VP of Clinical Affairs, VP of Operations and the Chief Information Officer. They will develop and deepen relationships with key vendors, maintain high-level relationships with trustees, monitor and encourage robust and productive working relationships between the Regions and Aurora Operations. They will also collaborate with the Business & Healthcare Analytics team and the Chief Underwriter to proactively assess the value of contracted programs and services and identify opportunities for improvement. ESSENTIAL JOB FUNCTIONS AND DUTIES Network Strategy & Optimization * Oversee the development of the Aurora Plans' network strategy to ensure operational excellence, scalability, modernization, and long-term sustainability * Guide the evaluation of current network performance, identification of gaps, and implementation of strategies to improve service quality, efficiency, and cost effectiveness * Work with teams to drive network innovation by assessing emerging technologies, industry trends, and competitive changes affecting strategic direction * Oversee strategic planning cycles, infrastructure roadmaps, and network transformation initiatives Vendor Management & Oversight * Direct the end-to-end vendor management function, including vendor selection, contracting, onboarding, performance management, and strategic alignment * Guide team to negotiate high-value contracts and partnerships to secure favorable terms, service levels, and financial benefits * Ensure vendor governance frameworks, SLAs, and performance scorecards are in place and managed to drive accountability * Build and maintain long-term strategic relationships with the leadership of key vendors, partners, and service providers Market Development & Growth * Build out a market development function to identify and evaluate new market opportunities, partnership models, and strategic alliances that support organizational growth and competitive positioning * Guide the team to analyze markets to assess industry landscapes, customer needs, and emerging trends * Oversee the development of new business initiatives, service offerings, or expansion plans that align with organizational goals * Partner with internal and external stakeholders to execute market development strategies that enhance value and drive sustainable growth Financial & Operational Management * Supervise financial planning, forecasting, cost modeling, and budgeting for network and vendor-related functions * Ensure efficient utilization of resources and deliver on targets related to cost savings, ROI, and operational improvements * Work closely with Aurora Plan Units VP of Clinical Affairs, VP of Operations and CIO to collaborate and align efforts Leadership & Team Development * Provide strategic leadership to teams responsible for network planning, optimization, vendor oversight, and market development, ensuring alignment with organizational goals and long-term growth strategies * Build, lead, and develop high-performing teams by setting clear expectations, fostering accountability, and cultivating a culture of excellence, collaboration, and continuous improvement * Coach and mentor team members and people leaders, providing guidance, performance feedback, and professional development opportunities that strengthen individual capabilities and organizational bench strength * Promote a learning-oriented environment that encourages innovation, cross-functional problem-solving, and adoption of best practices and emerging technologies * Model effective leadership behaviors, including transparency, integrity, strong communication, decisive action, and inclusive engagement across diverse teams * Drive talent development and succession planning, identifying high-potential employees and preparing future leaders for key roles within the network strategy and vendor management functions * Foster strong cross-functional relationships with operations, IT, finance, procurement, compliance, and executive leadership to ensure cohesive strategy execution and shared accountability * Champion organizational change, helping teams navigate transformation, new operating models, and evolving priorities with clarity and resilience * Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints * Supervises, leads, and delegates work and coaches, mentors, develops employees * Analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions * Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions * Assists with developing and coordinating policies and procedures * Responsible for the oversight of continued employee training requirements, safety, and quality initiatives * Exemplifies the Fund's values in leading and fostering a respectful, trusting and engaged culture of inclusion and engagement. ESSENTIAL QUALIFICATIONS * 15+ years of progressive leadership experience in network strategy, vendor management, and market development across complex, multi-partner environments * Bachelor's degree in business administration or related field from an accredited institution, or significant related experience in lieu of education * Master's Degree (preferred) in business administration, Healthcare Administration or Public Health or another related field * The ability to travel between 15 - 25% based on business needs * Proven ability to develop and execute enterprise-level network strategies that improve performance, reduce costs, and support long-term growth * Expertise in building and managing large-scale vendor ecosystems, including contract negotiation, SLA governance, performance optimization, and risk mitigation * Demonstrated success driving market expansion initiatives, developing new partnerships, and identifying strategic growth opportunities * Strong financial acumen with experience leading multimillion-dollar budgets, forecasting, cost modeling, and ROI-driven investment planning * Exceptional leadership skills with a track record of developing high-performing teams and influencing executives and cross-functional stakeholders * Highly skilled in data-driven decision-making, market and competitive analysis, and applying insights to guide strategic direction * Adept at leading complex transformation programs and navigating organizational change, ambiguity, and high-impact decision environments * Outstanding executive communication skills, with experience presenting to C-suite leaders, boards, regulators, and external partners * Deep understanding of industry technologies, network operations, regulatory requirements, and emerging trends that impact market and vendor strategies * Understanding of current benefits legislation (e.g., Employee Retirement Income Security Act (ERISA), Department of Labor (DOL), Internal Revenue Service (IRS), Consolidated Omnibus Budget Reconciliation Act (COBRA), and Health Insurance Portability and Accountability Act (HIPAA), etc.) * Strategic planning with the ability to translate fund priorities into measurable operational and vendor outcomes * Effective communication with boards of trustees, union leaders, employer groups, and external partners * Expertise in managing vendor ecosystems to maintain compliance and strategic alignment * Demonstrated success in supporting trustees with vendor accountability and value assessments. * Skilled at spotting market and partnership opportunities that deliver cost savings and improved member outcomes. * Strong background in implementing forward-thinking strategies without compromising continuity. * Skilled at navigating ambiguity and influencing cross-functional stakeholders. Salary range for this position: Salary $285,000 - $300,000. 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) as a remote employee with 15% - 25% travel based business needs. 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
    $285k-300k yearly Auto-Apply 9d ago
  • Content Producer (Seasonal)

    Major League Baseball Players Association 4.5company rating

    Remote job

    The Content Producer (Seasonal) is responsible for helping write, edit, create and manage Major League Baseball's club content and posting it to digital platforms during games. They work closely with assignment editors, supervising editors and beat reporters to ensure that our site and app presentation is accurate, timely, informative and fun. The role requires versatility, as all candidates will be expected to edit copy, navigate our content management systems and could also be called upon for reporting and newsletter coverage. It is first and foremost an editorial production position, and any fill-in writing opportunities are dependent on location and experience. We want someone who's a baseball nut and comfortable around stats, but also appreciates the lighter side of the game and is inclusive of the casual fan, can edit articles quickly and accurately, understands effective headlines and is intuitive about which types of content will resonate. This is not an office-based position and we will consider strong candidates from any U.S. location. Candidates who want to be seriously considered MUST include a cover letter with the application. Responsibilities Write, edit, fact-check and post content for use on MLB and team digital platforms React quickly and accurately during breaking news Craft entertaining headlines, captions and blurbs Package stories with video, photos, social media and other features Make judgments on story significance and arrange content into lead packages Communicate consistently with others on the content team on latest developments Qualifications & Skills Excellent writing and copyediting skills Experience with content management systems and web publishing Thorough grasp of baseball landscape and comfort with stats Work well under deadline and in fast-paced situations with multiple responsibilities Obsessive about accuracy Knowledge of social media and SEO Strong communication, presentation and organization skills Basic HTML and Photoshop skills a plus Must be available to work nights and weekends Pay Range: $22.00 - $25.00 per hour The actual offer will carefully consider a wide range of factors, including your work experience, education, skills, and any other factors MLB considers relevant to the hiring decision. Why MLB? Major League Baseball (MLB) is the most historic of the major professional sports leagues in the United States and Canada. Employees love working at MLB because of the culture of growth, teamwork, and professionalism. Employees who are most successful at MLB take initiative, know how to identify problems and provide solutions, and always put the Team first. For those ready to step up to the plate and join the major leagues, MLB takes the same approach as teams do with their players: empowering our “workforce athletes” to be at their best by engineering experiences that put employees in the best position to succeed. Major League Baseball is looking for candidates who are passionate about growing America's pastime to best serve its fans for decades to come. California Residents: Please see our California Recruitment Privacy Policy for more details. Colorado Residents: Colorado based applicants may redact or remove age-identifying information such as age, date of birth, or dates of school attendance or graduation. You will not be penalized for redacting or removing this information. Applicants requiring a reasonable accommodation for any part of the application and hiring process, please email us at accommodations@mlb.com. Requests received for non-disability related issues, such as following up on an application, will not receive a response. Are you ready to Step Up to the Plate? Apply below!
    $22-25 hourly Auto-Apply 5d ago
  • Sr. Account Representative

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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! Responsible for processing complex enrollments, elections, and monthly contributions in accordance with Summary Plan Documents (SPDs) and Collective Bargaining Agreements to ensure member eligibility for health coverage. Duties include reconciling monthly work reports; processing COBRA enrollments, member payments, and QMCSOs (validation, agency response, dependent setup, and eligibility tracking). Manages a complex account portfolio, including self-pay, FMLA/vacation hours, hybrid contribution plans, and retiree dental plans, potentially across multiple regions. Supports intermediate regression testing, runs reports/queries, trains employers on ESS, and supports initial phases of OLE/HSP plans. Provides training and ongoing support to new hires and team members, conducts audit-based coaching, and handles escalated issues in the absence of the supervisor. Serves as a key point of contact for employers, Customer Service, Claims, Regional Directors, Audit, and Legal. Manages daily employer communications related to work reports, payments, eligibility, and new hires, with a strong working knowledge of contracts, SPDs, and Collective Bargaining Agreements. ESSENTIAL JOB FUNCTIONS AND DUTIES * Determines if the member plan provides access to dependent coverage, and meets the requirements of the QMCSO * Ensures eligibility is updated timely to prevent problems with participants/dependents coverage seeking care * Partners with vendors to update urgent eligibility requests * Escalates recurring issues that delay eligibility to management * Applies credits and debits accurately in system * Maintains all QMCSO and COBRA/HIPAA files, including enrollment and payment documents * Maintains and monitors employee elections and related co-premiums * Maintains, monitors and reviews proof documents (marriage certificates, divorce decrees, birth certificates, etc.) for dependent coverage and related contributions * Updates member file in the eligibility system with terminated employees and new hire information * Verifies employer payments in US Bank to ensure all payments are processed * Monitors employer reports and refers late employers to the Legal Department * Monitors outstanding balances and notifies employers of monthly discrepancies through written correspondence. * Notifies members of payment discrepancies and cancellations through written correspondence * Reviews the weekly and monthly COBRA & Health Insurance Portability and Accountability Act (HIPAA) eligibility * Updates appropriate systems to track compliance and ensures that coverage is provided in accordance with the terms of the QMCSO * Trains new hires on new processes and procedures * Documents training provided and provides feedback to the staff and the management team * Audits accounts for purposes of coaching and development and provides feedback to the staff and management team * Exemplifies the Fund's BETTER Values and Professional Effectiveness Dimensions in contributing to a respectful, trusting, and engaged culture of diversity and inclusion ESSENTIAL QUALIFICATIONS * High School Diploma * 3 ~ 5 years of related experience * Working knowledge and experience in accounting, medical insurance, eligibility billing, delinquency procedures, reconciliation of payments, and collections * Preferable experience in eligibility rules including COBRA and Health Insurance Portability and Accountability Act (HIPAA), Employee Retirement Income Security Act (ERISA), and an understanding of Collective Bargaining Agreements Salary range for this position: Hourly $27.74 - $33.95, 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). We reward great work with great benefits, including but not limited to: 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, and Employee Assistance Program (EAP). #Li-Hybrid
    $27.7-34 hourly Auto-Apply 29d ago
  • Senior Data Engineer

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    Job Description 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're Hiring: Sr Data Engineer (Remote) UNITE HERE HEALTH is seeking a strategic and hands-on Sr Data Engineer to lead the development of our digital health data and analytics platform. As Data Engineering is new for our organization (1.5 years) this position is the first of its kind for this small, 6-person team. The role of Sr Data Engineer is pivotal in aligning business vision with technology strategy. Working closely with the Manager and Director of Data Engineering, as well as our senior Data Analytics team, you would drive innovation in data architecture and ensure compliance with industry-leading data privacy standards. What You'll Do: Have a hand in leading architecture and operations of our enterprise data platform Design scalable, modular data solutions across cloud platforms (Azure, AWS, GCP) Build and optimize data pipelines for batch and real-time processing Champion data governance, quality assurance, and automation Collaborate cross-functionally with IT, analytics, and reporting teams Ensure compliance with HITRUST, HIPAA, GDPR, SOC-II, and other standards Troubleshoot and resolve issues with data systems to minimize disruptions Manage vendor relationships and advocate for the right tech stack What You Bring: 10+ years in data management, engineering, and operations 7+ years in ETL/ELT and real-time data streaming architecture 5+ years architecting cloud-based platforms (Azure Data Factory, Snowflake, Databricks, etc.) Deep experience with healthcare data: medical/pharmacy claims, EDI transactions, lab data Strong command of Spark, Scala, Hive SQL, Kafka, Apache NiFi Experience with Azure analytics stack (Power BI, lakehouses, warehouses) Familiarity with MDM tools (Informatica, Profisee, Reltio) Bachelors in computer science, Healthcare Informatics, or related field (master's preferred) Experience within or interest in using Microsoft Fabric Build the Future of Healthcare Data with Us Join our mission-driven non-profit organization-celebrating over 50 years of service-dedicated to improving healthcare outcomes for the hard-working individuals our health benefits support. As a growing and stable organization, we offer the rare combination of long-term reliability and forward-thinking innovation. We foster a collaborative, inclusive culture that values diversity of thought and encourages creativity. In this role, you'll have direct opportunities to shape the future of our healthcare data platforms by designing scalable systems, optimizing data pipelines, and unlocking insights that drive better care. Salary range for this position: Salary $113,000 - $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) as a remote working opportunity. We reward great work with great benefits, including but not limited to: 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, and Employee Assistance Program (EAP). #LI-Remote
    $113k-142k yearly 3d ago
  • Claims Operations Director

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    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). #LI-REMOTE
    $137.2k-174.9k yearly Auto-Apply 11d ago
  • Nurse Navigator Medical Cost Management

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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 Nurse Navigator is a licensed clinical professional who supports members in navigating the healthcare system, coordinating care, and improving health outcomes. This role focuses on reducing unnecessary emergency room utilization, enhancing chronic disease management (especially for diabetes and ESRD), and promoting cost-effective care through education and network optimization. The Nurse Navigator works collaboratively with members, providers, and internal teams to address barriers to care and support population health initiatives. ESSENTIAL JOB FUNCTIONS AND DUTIES • Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization. • Educate members on chronic disease management, preventive care, and appropriate use of healthcare services, with a focus on diabetes and ESRD. • Identify and address social determinants of health (SDOH) that impact access to care and adherence to treatment plans. • Support members in locating in-network providers and facilities to reduce out-of-network and emergency room usage. • Coordinate referrals, post-discharge planning, and medication adherence strategies. • Collaborate with network case managers, social workers, and providers to ensure timely and appropriate care delivery. • Conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans. • Partner with community-based organizations to connect members with additional support services. • Document all member interactions and interventions in compliance with HIPAA and payer-specific guidelines. • Monitor and report trends related to gaps in care, member concerns, and program effectiveness. ESSENTIAL QUALIFICATIONS 3+ years of experience in care coordination, case management, or patient navigation. Spanish Bi-lingual skills (preferred). Strong understanding of health insurance plans, provider networks, and value-based care models. Clinical experience in chronic disease management, especially diabetes and ESRD. Excellent communication, critical thinking, and interpersonal skills. Ability to work with diverse populations and address health equity challenges. Proficiency in electronic health records (EHR) and payer systems. Bilingual language skills preferred. Experience in managed care or payer settings is a plus. Knowledge of community health resources and support service Strong understanding of health insurance plans, provider networks, and value-based care models. Clinical experience in chronic disease management, especially diabetes and ESRD. Proficiency in electronic health records (EHR) and payer systems. Knowledge of community health resources and support services. Experience in managed care or payer settings is a plus. - Education, Licenses, and Certifications • Registered Nurse (RN) license required • BSN or higher preferred. • Certified Diabetes Educator (CDE) or equivalent experience in diabetes education. • Certification in Case Management (CCM), Public Health (CPH), or similar credential. Salary range for this position: Salary $85,300 to $106.700. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid 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-Hybrid
    $85.3k-106.7k yearly Auto-Apply 60d+ ago
  • Director of Pharmacy Analytics

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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 looking for a Director of Pharmacy Analytics to prepare, develop, and assist in development of reporting and analytics associated with Pharmacy/Drug benefits. The position assists with maintenance and implementation of clinical edits and formulary documents with approval from clinical staff. This position has oversight of Analysts in the Pharmacy Analytics area. ESSENTIAL JOB FUNCTIONS AND DUTIES * Collects, maintains, edits, and organizes data necessary to prepare periodic reports on Pharmacy/Drug benefits * Develops and prepares special and ad hoc reports requested by internal parties related to Pharmacy/Drugs and assist clinical staff in making data driven decisions * Assists in maintenance and development of the Enterprise Data Warehouse (EDW) for Pharmacy data * Engages with consultants as needed and provides requested information * Strategizes with senior leadership regarding initiatives to continue to keep overall drug spend down * Assists in development of Pharmacy/Drug benefit EDW reporting * Collaborates with other departments in maintaining and providing Pharmacy benefit information (e.g., Analytics, Legal, Finance) * Assists with external Pharmacy reporting/analytics projects * Works with external contacts to complete requests or projects * Assists in maintaining, editing, and implementing clinical edits and formulary files as needed * Manages in development and implementation of Annual Transparency Reporting requirements * Maintains database for drug lookup tool * Oversees or works with Analytics staff and provides support and training * Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints * Supervises, leads, and delegates work and coaches, mentors, develops employees * Anticipates and analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions * Track annual progress of OOP accumulators and annual/lifetime Plan maximums; provide communication to impacted members when needed * Owns reports for Trustee/Manager Meetings with appropriate data analysis * Prepare Plan summaries for determination of creditable coverage status, file annual CMS creditable coverage disclosure * Oversees reporting and collection of rebate guarantees * Anticipates potential issues with vendors not meeting agreed upon performance guarantees in the areas of rebates and copay assistance * Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions * Reinforces the development and coordination of policies and procedures * Owns the oversight of continued employee training requirements, safety, and quality initiatives * Exemplifies the Fund's BETTER Values and Professional Effectiveness Dimensions in leading and fostering a respectful, trusting, and engaged culture of diversity and inclusion ESSENTIAL QUALIFICATIONS * 7 ~ 10 years of direct experience minimum, some of which is working in a PBM organization, or related field * Bachelor's degree in business Analysis or related field or equivalent work experience required * 5 ~ 7 years of supervisor experience required * Expert knowledge and experience performing analytics and reporting * Experience with design of reporting formats * Working knowledge of industry coding (revenue codes, International Classification of Diseases (ICD) 9 or 10's, Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT) codes, Medispan, etc.) * Working knowledge of SQL * Advanced level Power BI skills and application * Advanced level Microsoft Office skills (PowerPoint, Word, Access, Outlook) * Advanced level Microsoft Excel skills * Advanced level system(s) skills in SQL Salary range for this position: Salary $124,900 to $156,200. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a remote employee (central time zone preferred). 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
    $40k-76k yearly est. Auto-Apply 60d+ ago
  • Trending Content Writer/Editor (Seasonal)

    Major League Baseball Players Association 4.5company rating

    Remote job

    The Trending Content Writer/Editor will be someone who has their finger on the pulse of the baseball landscape, possessing both the ability to analyze which topics and storylines are driving the conversation among fans, as well as writing content that engages readers by pushing those conversations forward. This person should be a quick thinker and self-starter who is willing to take initiative. But they should also be a team player who is comfortable working collaboratively, taking direction and executing detailed instructions. The ability to work in a timely fashion and produce clean, concise and accurate copy is vitally important. The ideal candidate for this position possesses a deep understanding of all things baseball. Fluency in advanced/Statcast metrics is a plus, as is experience conducting statistical research and producing analysis of player and team performance. This is not an office-based position, and we will therefore consider candidates from any U.S. location. However, a flexible schedule is a must, including availability in the early morning (ET) and on weekends. Candidates who want to be seriously considered should include a cover letter with the application. Copies of and/or links to writing samples are also encouraged. Responsibilities Stay on top of which storylines are resonating with fans Move quickly to execute engaging written content centered on the day's trending topics Work closely with our editorial and mobile alerts teams to ensure timely publishing and distribution of articles Assist with a variety of other tasks as needed, including writing and editing push notifications through the MLB App; editing copy and handling web production tasks; and providing help with statistical research and analysis Qualifications & Skills Thorough knowledge of baseball, especially current players and trends, and comfort with the sport's terminology Strong grasp of the baseball media landscape and how to navigate social media to identify trending topics Exemplary news judgment The ability to write both quickly and accurately, with keen attention to detail regarding spelling, grammar and style Proficiency with SEO best practices Familiarity with baseball statistics and advanced metrics, including via Statcast The ability to conduct research through sites such as Baseball-Reference (including the Stathead tool), FanGraphs and Baseball Savant, with a willingness to learn new tools Experience with content management systems and web publishing Pay Range: $22.00-25.00 per hour The actual offer will carefully consider a wide range of factors, including your work experience, education, skills, and any other factors MLB considers relevant to the hiring decision. Why MLB? Major League Baseball (MLB) is the most historic of the major professional sports leagues in the United States and Canada. Employees love working at MLB because of the culture of growth, teamwork, and professionalism. Employees who are most successful at MLB take initiative, know how to identify problems and provide solutions, and always put the Team first. For those ready to step up to the plate and join the major leagues, MLB takes the same approach as teams do with their players: empowering our “workforce athletes” to be at their best by engineering experiences that put employees in the best position to succeed. Major League Baseball is looking for candidates who are passionate about growing America's pastime to best serve its fans for decades to come. California Residents: Please see our California Recruitment Privacy Policy for more details. Colorado Residents: Colorado based applicants may redact or remove age-identifying information such as age, date of birth, or dates of school attendance or graduation. You will not be penalized for redacting or removing this information. Applicants requiring a reasonable accommodation for any part of the application and hiring process, please email us at accommodations@mlb.com. Requests received for non-disability related issues, such as following up on an application, will not receive a response. Are you ready to Step Up to the Plate? Apply below!
    $22-25 hourly Auto-Apply 5d ago
  • Director of Claims Cost Management

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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'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. ESSENTIAL JOB FUNCTIONS AND DUTIES * 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. ESSENTIAL QUALIFICATIONS * 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. Establishing goals and achieving measurable results, serve as operational lead for implementing 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, prepare and present reports, analytic dashboards and recommendations, developing and coordinating policies and procedures. * Knowledge: Regulatory, compliance, audit requirements, vender 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: 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% - 25% travel. 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-HYBRID
    $137.2k-174.9k yearly Auto-Apply 29d ago
  • Claims Adjudicator II

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    UNITE HERE HEALTH serves 190,000+ 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 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. ESSENTIAL JOB FUNCTIONS AND DUTIES * 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 ESSENTIAL 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 it's related processes * Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes * Fluency (speak and write) in Spanish, preferred 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) We reward great work with great benefits, including but not limited to: 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, and Employee Assistance Program (EAP). #Remote
    $20.4-25 hourly Auto-Apply 40d ago
  • Sr. Account Representative

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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!
    $44k-68k yearly est. Auto-Apply 31d ago
  • Senior Data Engineer

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    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're Hiring: Sr Data Engineer (Remote) UNITE HERE HEALTH is seeking a strategic and hands-on Sr Data Engineer to lead the development of our digital health data and analytics platform. As Data Engineering is new for our organization (1.5 years) this position is the first of its kind for this small, 6-person team. The role of Sr Data Engineer is pivotal in aligning business vision with technology strategy. Working closely with the Manager and Director of Data Engineering, as well as our senior Data Analytics team, you would drive innovation in data architecture and ensure compliance with industry-leading data privacy standards. What You'll Do: Have a hand in leading architecture and operations of our enterprise data platform Design scalable, modular data solutions across cloud platforms (Azure, AWS, GCP) Build and optimize data pipelines for batch and real-time processing Champion data governance, quality assurance, and automation Collaborate cross-functionally with IT, analytics, and reporting teams Ensure compliance with HITRUST, HIPAA, GDPR, SOC-II, and other standards Troubleshoot and resolve issues with data systems to minimize disruptions Manage vendor relationships and advocate for the right tech stack What You Bring: 10+ years in data management, engineering, and operations 7+ years in ETL/ELT and real-time data streaming architecture 5+ years architecting cloud-based platforms (Azure Data Factory, Snowflake, Databricks, etc.) Deep experience with healthcare data: medical/pharmacy claims, EDI transactions, lab data Strong command of Spark, Scala, Hive SQL, Kafka, Apache NiFi Experience with Azure analytics stack (Power BI, lakehouses, warehouses) Familiarity with MDM tools (Informatica, Profisee, Reltio) Bachelors in computer science, Healthcare Informatics, or related field (master's preferred) Experience within or interest in using Microsoft Fabric Build the Future of Healthcare Data with Us Join our mission-driven non-profit organization-celebrating over 50 years of service-dedicated to improving healthcare outcomes for the hard-working individuals our health benefits support. As a growing and stable organization, we offer the rare combination of long-term reliability and forward-thinking innovation. We foster a collaborative, inclusive culture that values diversity of thought and encourages creativity. In this role, you'll have direct opportunities to shape the future of our healthcare data platforms by designing scalable systems, optimizing data pipelines, and unlocking insights that drive better care. Salary range for this position: Salary $113,000 - $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) as a remote working opportunity. We reward great work with great benefits, including but not limited to: 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, and Employee Assistance Program (EAP). #LI-Remote
    $113k-142k yearly Auto-Apply 60d+ ago
  • Nurse Navigator Medical Cost Management

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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 Nurse Navigator is a licensed clinical professional who supports members in navigating the healthcare system, coordinating care, and improving health outcomes. This role focuses on reducing unnecessary emergency room utilization, enhancing chronic disease management (especially for diabetes and ESRD), and promoting cost-effective care through education and network optimization. The Nurse Navigator works collaboratively with members, providers, and internal teams to address barriers to care and support population health initiatives. ESSENTIAL JOB FUNCTIONS AND DUTIES * Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization. * Educate members on chronic disease management, preventive care, and appropriate use of healthcare services, with a focus on diabetes and ESRD. * Identify and address social determinants of health (SDOH) that impact access to care and adherence to treatment plans. * Support members in locating in-network providers and facilities to reduce out-of-network and emergency room usage. * Coordinate referrals, post-discharge planning, and medication adherence strategies. * Collaborate with network case managers, social workers, and providers to ensure timely and appropriate care delivery. * Conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans. * Partner with community-based organizations to connect members with additional support services. * Document all member interactions and interventions in compliance with HIPAA and payer-specific guidelines. * Monitor and report trends related to gaps in care, member concerns, and program effectiveness. ESSENTIAL QUALIFICATIONS * 3+ years of experience in care coordination, case management, or patient navigation. * Spanish Bi-lingual skills (preferred). * Strong understanding of health insurance plans, provider networks, and value-based care models. * Clinical experience in chronic disease management, especially diabetes and ESRD. * Excellent communication, critical thinking, and interpersonal skills. * Ability to work with diverse populations and address health equity challenges. * Proficiency in electronic health records (EHR) and payer systems. * Bilingual language skills preferred. * Experience in managed care or payer settings is a plus. * Knowledge of community health resources and support service * Strong understanding of health insurance plans, provider networks, and value-based care models. * Clinical experience in chronic disease management, especially diabetes and ESRD. * Proficiency in electronic health records (EHR) and payer systems. * Knowledge of community health resources and support services. * Experience in managed care or payer settings is a plus. * Education, Licenses, and Certifications * Registered Nurse (RN) license required * BSN or higher preferred. * Certified Diabetes Educator (CDE) or equivalent experience in diabetes education. * Certification in Case Management (CCM), Public Health (CPH), or similar credential. Salary range for this position: Salary $85,300 to $106.700. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid 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-Hybrid
    $85.3k-106.7k yearly Auto-Apply 60d+ ago
  • VP of Network Strategy & Market Development

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    Job Description 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 Vice President of Network Strategy & Market Development is a senior executive leader responsible for designing, executing, and optimizing Aurora's managed care plan and provider network and market management strategy. This role provides strategic and operational leadership to the Fund's Aurora staff and oversee network contracting, provider partnerships, vendor management, and market development to ensure the organization delivers competitive, high-quality, cost-effective care solutions across Aurora's regions/markets. This position is a key contributor to the overall performance of the Aurora-based Plan. This role will provide overall strategic guidance to the Aurora Plan Units, leading the development of a comprehensive network strategy-including contracting with managed care plans, direct contracts with hospital systems, provider groups, and ancillary service providers to strengthen our Aurora plan performance on cost and position the organization for increased growth. This position directs the negotiation and management of health plan, provider, and other vendor agreements, cultivates strategic partnerships with health systems, key physician groups, and other strategic market partners, and ensures strong operational performance of contracted vendors/providers. The leader also oversees vendor selection and performance to support network adequacy, access, and service delivery. Working closely with executive leadership, the VP analyzes market trends, competitive dynamics, and regulatory changes to identify opportunities for expansion and differentiation. The role is accountable for vendor and market performance metrics, total cost of care initiatives as it relates to contracting, and market-level business results related to our contracts. This position requires strong strategic vision, deep managed care expertise, cross-functional collaboration, and the ability to influence both internal and external stakeholders. Key Functions Include: Vendor Management The Vice President will oversee a vendor management team (MCVA) to ensure that upon the closure of critical deals with vendors, all onboarding and implementation issues are addressed, and performance is monitored closely to extract full value from vendor partnerships. Under the direction of the Vice President, the MCVA Team will support final negotiations; coordinate with internal and external stakeholders to implement contracts; and manage day-to-day contractual relationships with a wide range of managed care partners (contracted network carriers, vendors and preferred providers). Network Contracting Strategy and Execution The Vice President will oversee the network contracting strategy and execution team and provide expert guidance in the design, negotiation and execution of advanced contracting models and cultivation of key provider partnerships. They will ensure UHH's contracting strategy is centered around improving affordability, quality and overall network performance. The Vice President will drive innovation in UHH's contracting strategy, including the exploration of opportunities to increase quality and decrease costs through both standard and novel arrangements with third party administrators, direct contracts with providers, value-based contracts, carve outs, point solutions and other approaches that deliver value. Market Development The Vice President will provide oversight to the team to build a deep understanding of major UHH markets (Chicago, NYC, Boston, AC, national Food Service Plan) and provide clear guidance on where to invest, intervene or innovate. They will guide the examination of key trends, market dynamics, local legislation and policy activity, and union and employer points of view to anticipate future impacts and translate intelligence into actionable, market-specific strategies that increase quality, decrease costs and deliver positive member experience. The Vice President will work in close collaboration with peers, including the Aurora Plan Units VP of Clinical Affairs, VP of Operations and the Chief Information Officer. They will develop and deepen relationships with key vendors, maintain high-level relationships with trustees, monitor and encourage robust and productive working relationships between the Regions and Aurora Operations. They will also collaborate with the Business & Healthcare Analytics team and the Chief Underwriter to proactively assess the value of contracted programs and services and identify opportunities for improvement. ESSENTIAL JOB FUNCTIONS AND DUTIES Network Strategy & Optimization Oversee the development of the Aurora Plans' network strategy to ensure operational excellence, scalability, modernization, and long-term sustainability Guide the evaluation of current network performance, identification of gaps, and implementation of strategies to improve service quality, efficiency, and cost effectiveness Work with teams to drive network innovation by assessing emerging technologies, industry trends, and competitive changes affecting strategic direction Oversee strategic planning cycles, infrastructure roadmaps, and network transformation initiatives Vendor Management & Oversight Direct the end-to-end vendor management function, including vendor selection, contracting, onboarding, performance management, and strategic alignment Guide team to negotiate high-value contracts and partnerships to secure favorable terms, service levels, and financial benefits Ensure vendor governance frameworks, SLAs, and performance scorecards are in place and managed to drive accountability Build and maintain long-term strategic relationships with the leadership of key vendors, partners, and service providers Market Development & Growth Build out a market development function to identify and evaluate new market opportunities, partnership models, and strategic alliances that support organizational growth and competitive positioning Guide the team to analyze markets to assess industry landscapes, customer needs, and emerging trends Oversee the development of new business initiatives, service offerings, or expansion plans that align with organizational goals Partner with internal and external stakeholders to execute market development strategies that enhance value and drive sustainable growth Financial & Operational Management Supervise financial planning, forecasting, cost modeling, and budgeting for network and vendor-related functions Ensure efficient utilization of resources and deliver on targets related to cost savings, ROI, and operational improvements Work closely with Aurora Plan Units VP of Clinical Affairs, VP of Operations and CIO to collaborate and align efforts Leadership & Team Development Provide strategic leadership to teams responsible for network planning, optimization, vendor oversight, and market development, ensuring alignment with organizational goals and long-term growth strategies Build, lead, and develop high-performing teams by setting clear expectations, fostering accountability, and cultivating a culture of excellence, collaboration, and continuous improvement Coach and mentor team members and people leaders, providing guidance, performance feedback, and professional development opportunities that strengthen individual capabilities and organizational bench strength Promote a learning-oriented environment that encourages innovation, cross-functional problem-solving, and adoption of best practices and emerging technologies Model effective leadership behaviors, including transparency, integrity, strong communication, decisive action, and inclusive engagement across diverse teams Drive talent development and succession planning, identifying high-potential employees and preparing future leaders for key roles within the network strategy and vendor management functions Foster strong cross-functional relationships with operations, IT, finance, procurement, compliance, and executive leadership to ensure cohesive strategy execution and shared accountability Champion organizational change, helping teams navigate transformation, new operating models, and evolving priorities with clarity and resilience Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints Supervises, leads, and delegates work and coaches, mentors, develops employees Analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions Assists with developing and coordinating policies and procedures Responsible for the oversight of continued employee training requirements, safety, and quality initiatives Exemplifies the Fund's values in leading and fostering a respectful, trusting and engaged culture of inclusion and engagement. ESSENTIAL QUALIFICATIONS 15+ years of progressive leadership experience in network strategy, vendor management, and market development across complex, multi-partner environments Bachelor's degree in business administration or related field from an accredited institution, or significant related experience in lieu of education Master's Degree (preferred) in business administration, Healthcare Administration or Public Health or another related field The ability to travel between 15 - 25% based on business needs Proven ability to develop and execute enterprise-level network strategies that improve performance, reduce costs, and support long-term growth Expertise in building and managing large-scale vendor ecosystems, including contract negotiation, SLA governance, performance optimization, and risk mitigation Demonstrated success driving market expansion initiatives, developing new partnerships, and identifying strategic growth opportunities Strong financial acumen with experience leading multimillion-dollar budgets, forecasting, cost modeling, and ROI-driven investment planning Exceptional leadership skills with a track record of developing high-performing teams and influencing executives and cross-functional stakeholders Highly skilled in data-driven decision-making, market and competitive analysis, and applying insights to guide strategic direction Adept at leading complex transformation programs and navigating organizational change, ambiguity, and high-impact decision environments Outstanding executive communication skills, with experience presenting to C-suite leaders, boards, regulators, and external partners Deep understanding of industry technologies, network operations, regulatory requirements, and emerging trends that impact market and vendor strategies Understanding of current benefits legislation (e.g., Employee Retirement Income Security Act (ERISA), Department of Labor (DOL), Internal Revenue Service (IRS), Consolidated Omnibus Budget Reconciliation Act (COBRA), and Health Insurance Portability and Accountability Act (HIPAA), etc.) Strategic planning with the ability to translate fund priorities into measurable operational and vendor outcomes Effective communication with boards of trustees, union leaders, employer groups, and external partners Expertise in managing vendor ecosystems to maintain compliance and strategic alignment Demonstrated success in supporting trustees with vendor accountability and value assessments. Skilled at spotting market and partnership opportunities that deliver cost savings and improved member outcomes. Strong background in implementing forward-thinking strategies without compromising continuity. Skilled at navigating ambiguity and influencing cross-functional stakeholders. Salary range for this position: Salary $285,000 - $300,000. 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) as a remote employee with 15% - 25% travel based business needs. 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
    $285k-300k yearly 9d ago
  • Claims Supervisor

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    Job Description UNITE HERE HEALTH serves 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 Claims Supervisor will oversee the claims production team who is scanning, uploading and keying in UNITE HERE HEALTH's member's and dependent's medical, vision, dental and short-term disability claims related correspondence. This position is responsible for the accuracy and timeliness of handling of claims and member correspondence based on the guidelines set forth by the Department of Labor. The Claims Supervisor is responsible for partnering with internal and external parties to ensure that the turnaround times are met, which includes, but is not limited to the BlueCross and BlueShield incentive. This position is relied upon as a subject matter expert for creating and updating provider records, Coordination of Benefits provisions and eligibility-related inquiries within the Department; this includes providing support to the Legal Team as it relates to subrogation files. The Claims Supervisor supports the production team through functions in collaboration and coordination with other teams, including New Membership, Member Services and C&E teams. To provide daily support to the Claims Department through updates to members COB information and providers records in the claims processing system. This position provides development, training, and coaching to employees for guidance and direction to ensure that a high level of accountability and performance is delivered to our participants. ESSENTIAL JOB FUNCTIONS AND DUTIES Provides leadership, motivates, advocates, coaches and develops team performance and promotes Fund culture/mission along with advocating for appropriate change with a positive attitude Holds direct reports accountable for individual performance, which may result in disciplinary action Promotes operational efficiency and quality by critically analyzing team processes with the intention of improving member experience and creating a high level of consistency in the team's quality and production results. Manages and reports on team inventory to ensure that departmental metrics are met Successfully investigates and responds to escalated inquiries from internal and external sources Allocates and cross trains team resources to complete goals Assists in training to other UHH operational areas Collaborates and partners with other Claims Department Supervisors to ensure consistency in processing across all teams and to identify ways to be BETTER, more efficient, adaptable and participant focused Ensures adherence to policies and procedures are consistently applied Assists in the design and preparation of management reports Collaborates with the Legal team to understand legal regulations and plan provisions Demonstrates necessary competence in technical, industry standard and soft skills to effectively support and develop staff Communicates with Executive Leadership through creation of the monthly Claims Department Dashboard. Interacts with members and UHH operational areas to resolve complex issues Interacts with members and UHH operational areas to educate regarding policies and procedures Strictly adheres to all regulatory and legal requirements, including time deadlines Ensures members Coordination of Benefits information is accurately and consistently updated and maintained Oversees the creation and maintenance of provider records for accuracy and claim payments, as well as, annual 1099 reporting to IRS Demonstrates personal accountability for personal actions as well as team and departmental results through ensuring claims and correspondence are handled in accordance with the guidelines set forth by the DOL and our internal Claims Policy Committee Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints Supervises, leads, and delegates work and coaches, mentors, develops employees Analyzes problems, identifies and develops alternative solutions, projects consequences of proposed actions and implements recommendation/solutions Recommends hires and promotions, directs and evaluates employment decisions for all assigned positions Assists with developing and coordinating policies and procedures Responsible for the oversight of continued employee training requirements, safety and quality initiatives ESSENTIAL QUALIFICATIONS: Bachelor's degree in related field or equivalent work experience required 4 ~ 6 years of direct experience minimum 3 ~ 5 years of supervisory experience required Preferred fluency (speak and write) in Spanish Intermediate level Microsoft Office and Excel skills Professional level training that provides working knowledge of: Administration of welfare plan benefits High degree of Claims Processing Knowledge Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA Audit and billing procedures Plan documents and summary plan descriptions Vendor relations Eligibility rules Salary range for this position: Salary $70,500- $88,200. 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: Monday~Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid (mostly work from home) opportunity with quarterly (approx.) in-office time. 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 #LI-LY-3
    $70.5k-88.2k yearly 6d ago
  • Director of Pharmacy Analytics

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    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 looking for a Director of Pharmacy Analytics to prepare, develop, and assist in development of reporting and analytics associated with Pharmacy/Drug benefits. The position assists with maintenance and implementation of clinical edits and formulary documents with approval from clinical staff. This position has oversight of Analysts in the Pharmacy Analytics area. ESSENTIAL JOB FUNCTIONS AND DUTIES Collects, maintains, edits, and organizes data necessary to prepare periodic reports on Pharmacy/Drug benefits Develops and prepares special and ad hoc reports requested by internal parties related to Pharmacy/Drugs and assist clinical staff in making data driven decisions Assists in maintenance and development of the Enterprise Data Warehouse (EDW) for Pharmacy data Engages with consultants as needed and provides requested information Strategizes with senior leadership regarding initiatives to continue to keep overall drug spend down Assists in development of Pharmacy/Drug benefit EDW reporting Collaborates with other departments in maintaining and providing Pharmacy benefit information (e.g., Analytics, Legal, Finance) Assists with external Pharmacy reporting/analytics projects Works with external contacts to complete requests or projects Assists in maintaining, editing, and implementing clinical edits and formulary files as needed Manages in development and implementation of Annual Transparency Reporting requirements Maintains database for drug lookup tool Oversees or works with Analytics staff and provides support and training Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints Supervises, leads, and delegates work and coaches, mentors, develops employees Anticipates and analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions Track annual progress of OOP accumulators and annual/lifetime Plan maximums; provide communication to impacted members when needed Owns reports for Trustee/Manager Meetings with appropriate data analysis Prepare Plan summaries for determination of creditable coverage status, file annual CMS creditable coverage disclosure Oversees reporting and collection of rebate guarantees Anticipates potential issues with vendors not meeting agreed upon performance guarantees in the areas of rebates and copay assistance Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions Reinforces the development and coordination of policies and procedures Owns the oversight of continued employee training requirements, safety, and quality initiatives Exemplifies the Fund's BETTER Values and Professional Effectiveness Dimensions in leading and fostering a respectful, trusting, and engaged culture of diversity and inclusion ESSENTIAL QUALIFICATIONS 7 ~ 10 years of direct experience minimum, some of which is working in a PBM organization, or related field Bachelor's degree in business Analysis or related field or equivalent work experience required 5 ~ 7 years of supervisor experience required Expert knowledge and experience performing analytics and reporting Experience with design of reporting formats Working knowledge of industry coding (revenue codes, International Classification of Diseases (ICD) 9 or 10's, Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT) codes, Medispan, etc.) Working knowledge of SQL Advanced level Power BI skills and application Advanced level Microsoft Office skills (PowerPoint, Word, Access, Outlook) Advanced level Microsoft Excel skills Advanced level system(s) skills in SQL Salary range for this position: Salary $124,900 to $156,200. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a remote employee (central time zone preferred). 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
    $40k-76k yearly est. Auto-Apply 60d+ ago
  • Senior Data Engineer

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL or remote

    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're Hiring: Sr Data Engineer (Remote) UNITE HERE HEALTH is seeking a strategic and hands-on Sr Data Engineer to lead the development of our digital health data and analytics platform. As Data Engineering is new for our organization (1.5 years) this position is the first of its kind for this small, 6-person team. The role of Sr Data Engineer is pivotal in aligning business vision with technology strategy. Working closely with the Manager and Director of Data Engineering, as well as our senior Data Analytics team, you would drive innovation in data architecture and ensure compliance with industry-leading data privacy standards. What You'll Do: Have a hand in leading architecture and operations of our enterprise data platform Design scalable, modular data solutions across cloud platforms ( Azure , AWS, GCP) Build and optimize data pipelines for batch and real-time processing Champion data governance, quality assurance, and automation Collaborate cross-functionally with IT, analytics, and reporting teams Ensure compliance with HITRUST, HIPAA, GDPR, SOC-II, and other standards Troubleshoot and resolve issues with data systems to minimize disruptions Manage vendor relationships and advocate for the right tech stack What You Bring: 10+ years in data management, engineering, and operations 7+ years in ETL/ELT and real-time data streaming architecture 5+ years architecting cloud-based platforms (Azure Data Factory, Snowflake, Databricks, etc.) Deep experience with healthcare data: medical/pharmacy claims, EDI transactions, lab data Strong command of Spark, Scala, Hive SQL, Kafka, Apache NiFi Experience with Azure analytics stack (Power BI, lakehouses, warehouses) Familiarity with MDM tools (Informatica, Profisee, Reltio) Bachelors in computer science, Healthcare Informatics, or related field (master's preferred) Experience within or interest in using Microsoft Fabric Build the Future of Healthcare Data with Us Join our mission-driven non-profit organization-celebrating over 50 years of service-dedicated to improving healthcare outcomes for the hard-working individuals our health benefits support. As a growing and stable organization, we offer the rare combination of long-term reliability and forward-thinking innovation. We foster a collaborative, inclusive culture that values diversity of thought and encourages creativity. In this role, you'll have direct opportunities to shape the future of our healthcare data platforms by designing scalable systems, optimizing data pipelines, and unlocking insights that drive better care. Salary range for this position: Salary $113,000 - $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) as a remote working opportunity. We reward great work with great benefits, including but not limited to: 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, and Employee Assistance Program (EAP). #LI-Remote
    $113k-142k yearly Auto-Apply 60d+ ago
  • Nurse Navigator Medical Cost Management

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    Job Description 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 Nurse Navigator is a licensed clinical professional who supports members in navigating the healthcare system, coordinating care, and improving health outcomes. This role focuses on reducing unnecessary emergency room utilization, enhancing chronic disease management (especially for diabetes and ESRD), and promoting cost-effective care through education and network optimization. The Nurse Navigator works collaboratively with members, providers, and internal teams to address barriers to care and support population health initiatives. ESSENTIAL JOB FUNCTIONS AND DUTIES • Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization. • Educate members on chronic disease management, preventive care, and appropriate use of healthcare services, with a focus on diabetes and ESRD. • Identify and address social determinants of health (SDOH) that impact access to care and adherence to treatment plans. • Support members in locating in-network providers and facilities to reduce out-of-network and emergency room usage. • Coordinate referrals, post-discharge planning, and medication adherence strategies. • Collaborate with network case managers, social workers, and providers to ensure timely and appropriate care delivery. • Conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans. • Partner with community-based organizations to connect members with additional support services. • Document all member interactions and interventions in compliance with HIPAA and payer-specific guidelines. • Monitor and report trends related to gaps in care, member concerns, and program effectiveness. ESSENTIAL QUALIFICATIONS 3+ years of experience in care coordination, case management, or patient navigation. Spanish Bi-lingual skills (preferred). Strong understanding of health insurance plans, provider networks, and value-based care models. Clinical experience in chronic disease management, especially diabetes and ESRD. Excellent communication, critical thinking, and interpersonal skills. Ability to work with diverse populations and address health equity challenges. Proficiency in electronic health records (EHR) and payer systems. Bilingual language skills preferred. Experience in managed care or payer settings is a plus. Knowledge of community health resources and support service Strong understanding of health insurance plans, provider networks, and value-based care models. Clinical experience in chronic disease management, especially diabetes and ESRD. Proficiency in electronic health records (EHR) and payer systems. Knowledge of community health resources and support services. Experience in managed care or payer settings is a plus. - Education, Licenses, and Certifications • Registered Nurse (RN) license required • BSN or higher preferred. • Certified Diabetes Educator (CDE) or equivalent experience in diabetes education. • Certification in Case Management (CCM), Public Health (CPH), or similar credential. Salary range for this position: Salary $85,300 to $106.700. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid 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-Hybrid
    $85.3k-106.7k yearly 19d ago
  • Director of Pharmacy Analytics

    Unite Here Health 4.5company rating

    Unite Here Health job in Oak Brook, IL

    Job Description 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 looking for a Director of Pharmacy Analytics to prepare, develop, and assist in development of reporting and analytics associated with Pharmacy/Drug benefits. The position assists with maintenance and implementation of clinical edits and formulary documents with approval from clinical staff. This position has oversight of Analysts in the Pharmacy Analytics area. ESSENTIAL JOB FUNCTIONS AND DUTIES Collects, maintains, edits, and organizes data necessary to prepare periodic reports on Pharmacy/Drug benefits Develops and prepares special and ad hoc reports requested by internal parties related to Pharmacy/Drugs and assist clinical staff in making data driven decisions Assists in maintenance and development of the Enterprise Data Warehouse (EDW) for Pharmacy data Engages with consultants as needed and provides requested information Strategizes with senior leadership regarding initiatives to continue to keep overall drug spend down Assists in development of Pharmacy/Drug benefit EDW reporting Collaborates with other departments in maintaining and providing Pharmacy benefit information (e.g., Analytics, Legal, Finance) Assists with external Pharmacy reporting/analytics projects Works with external contacts to complete requests or projects Assists in maintaining, editing, and implementing clinical edits and formulary files as needed Manages in development and implementation of Annual Transparency Reporting requirements Maintains database for drug lookup tool Oversees or works with Analytics staff and provides support and training Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints Supervises, leads, and delegates work and coaches, mentors, develops employees Anticipates and analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions Track annual progress of OOP accumulators and annual/lifetime Plan maximums; provide communication to impacted members when needed Owns reports for Trustee/Manager Meetings with appropriate data analysis Prepare Plan summaries for determination of creditable coverage status, file annual CMS creditable coverage disclosure Oversees reporting and collection of rebate guarantees Anticipates potential issues with vendors not meeting agreed upon performance guarantees in the areas of rebates and copay assistance Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions Reinforces the development and coordination of policies and procedures Owns the oversight of continued employee training requirements, safety, and quality initiatives Exemplifies the Fund's BETTER Values and Professional Effectiveness Dimensions in leading and fostering a respectful, trusting, and engaged culture of diversity and inclusion ESSENTIAL QUALIFICATIONS 7 ~ 10 years of direct experience minimum, some of which is working in a PBM organization, or related field Bachelor's degree in business Analysis or related field or equivalent work experience required 5 ~ 7 years of supervisor experience required Expert knowledge and experience performing analytics and reporting Experience with design of reporting formats Working knowledge of industry coding (revenue codes, International Classification of Diseases (ICD) 9 or 10's, Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT) codes, Medispan, etc.) Working knowledge of SQL Advanced level Power BI skills and application Advanced level Microsoft Office skills (PowerPoint, Word, Access, Outlook) Advanced level Microsoft Excel skills Advanced level system(s) skills in SQL Salary range for this position: Salary $124,900 to $156,200. 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 thru Friday, 7.5 hours per day (37.5 hours per week) as a remote employee (central time zone preferred). 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
    $40k-76k yearly est. 3d ago

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