Director of Out of Network Claims Negotiations

2 weeks ago

Bedminster, Pennsylvania, United States Zelis Healthcare Full time

Job Summary:

The Director of Out of Network Claims Negotiations is responsible for overseeing the daily operations of the Out of Network Negotiation department. This includes managing staff and ensuring production quality meets or exceeds defined Key Performance Indicators (KPIs).

Key Responsibilities:

  • Ownership of all aspects of performance, training, coaching, team structure and scalability, and career pathing as it relates to all managers and associates within the OON Negotiations department.
  • Identify and implement strategic initiatives to drive savings and revenue with a focus on all areas of OON product but a primary focus on Negotiations and Choice Agreements.
  • Identify and implement process and system enhancements including but not limited to the Negotiation SOP's, Negotiations UI, Auto-distribution, and Auto-fax to drive efficiency and savings within the negotiation teams.
  • Achieve or surpass monthly and annual revenue targets within Negotiations and OON product as a whole.
  • Collaborate with Product and others as needed to implement product initiatives to drive savings and revenue for the OON product.
  • Build and Monitor Negotiation KPI's to ensure product performance to furthermore investigate both positive and negative trends such as volume, hit rate, savings rate, & Choice agreements.
  • Partner with UAT team on deployment work that may impact Negotiations.
  • Partner with Auditing to identify key alerts to drive Quality Assurance within Negotiations.
  • Mentor and coach management within the Out of Network (OON) Negotiations team.
  • Collaborate with leadership and People & Culture on performance management matters.
  • Address escalated client issues, such as provider disputes and special requests.
  • Support associates in troubleshooting system-related challenges.
  • Partner with the Provider Services Department to address provider issues, including contract and discount disputes.
  • Analyze negotiation product trends to provide initiatives to drive further savings/revenue and efficiencies.
  • Collaborate cross-departmentally to achieve results as intended.
  • Maintain awareness of and ensure adherence to Zelis standards regarding privacy.
  • Must be available to travel 10% - 20% as required to meet business needs.

Requirements:

  • Bachelor's degree or historical equivalent experience.
  • 10+ years of experience in claims processing.
  • 5+ years of experience managing a team of 20+ within Claims Operations.
  • Proven expertise in processing and negotiating all Out of Network claims.
  • A self-starter with an ability to research and resolve issues.
  • Strategic mindset with ability to identify and implement new ideas.
  • Management of strategic operational and technology initiatives. Experience managing projects and process innovative changes effectively.
  • Strong working knowledge of MS Excel, computer systems, applications and operating systems.
  • Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships.
  • Excellent skills in critical thinking and analysis, project management, meeting facilitation, and interpersonal interactions (e.g., partnering, conflict management, consulting, etc.).
  • Ability to create and document workflow processes.

Location and Workplace Flexibility:

Zelis is a modern healthcare financial experience company that provides a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. We foster a hybrid and remote-friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team.

Zelis is proud to be an equal opportunity employer. We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email .

We will never ask for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.

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