Director Out of Network Services

Zelis Healthcare - St. Louis, MO

Full-time - Senior

Remote - St. Louis, MO

Professional, Scientific, and Technical Services

About the position

The Director of Out of Network Services is responsible for overseeing the operations and performance of the Out of Network Post Pay Solutions department. This role focuses on ensuring that the department meets quality, productivity, and compliance standards while developing strategies to enhance efficiency and effectiveness in out of network post pay processes and systems.

Responsibilities

• Manage the day-to-day operations of the out of network post pay department, including staff supervision, workload distribution, performance evaluation, and coaching.
• Monitor and analyze key performance indicators such as retained savings, turnaround time, quality assurance, and customer satisfaction.
• Identify and implement opportunities for process improvement, cost reduction, and service enhancement.
• Ensure compliance with company policies, procedures, and contractual obligations related to out of network claims.
• Collaborate with other departments to resolve complex or escalated issues and ensure customer satisfaction.
• Develop and maintain positive relationships with external stakeholders, including providers, payers, and regulators.
• Stay abreast of industry trends, best practices, and regulatory changes related to out of network claims.
• Prepare and present reports and recommendations to senior management and clients on the performance and improvement of the out of network post pay team.

Requirements

• Bachelor's degree in business administration, health care management, or related field.
• Minimum of 10 years of experience in health care claims processing, with at least 5 years in a managerial or supervisory role.
• Extensive knowledge of out of network claims policies, procedures, and regulations.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent communication, interpersonal, and leadership skills.
• Proficient in Microsoft Office and claims processing software.
• Expertise in fully insured & self-insured market segments.
• Experience managing client relationships.