Manager, Claims Negotiations
ABOUT ZELIS (STANDARD):
As the leading payments company in healthcare, we price, and explain healthcare for payers, providers, and healthcare consumers. Zelis was founded on a belief there is a better way to determine the cost of a healthcare claim, manage payment-related data, and make the payment because more affordable and transparent care is good for all of us. We partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, to manage the complete claim pricing process.
The Manager, Claims Negotiations will oversee various functions within the Out of Network Services Department. This includes assisting in the supervision of Claim Negotiators, closely monitoring claim volume and turnaround time, as well as new client claims, revenue opportunities, and savings quotas. Additionally, the Manager will actively contribute to the improvement and development of policies and procedures.
- Monitor and track overall claim activity related to fee negotiations and ensuring compliance with all turnaround time requirements.
- Manage a dedicated team of Claim Negotiators responsible for negotiating claims, providing direction on negotiations, utilizing tools and resources effectively, and tracking performance. Conduct regular reviews of quotas on a monthly and quarterly basis.
- Assist in the daily distribution of claims to appropriate team members.
- Review and process Non-Acceptances during the day to ensure appropriateness and identify potential savings opportunities.
- Identify specific claims that require processing outside the client's normal services and seek client approval for processing according to Zelis' recommendations.
- Participate in the interview process for new staff and train new Claim Negotiators using relevant training materials, regularly reviewing, and updating training materials.
- Provide ongoing education and training to the Claim Negotiators through meetings and seminars.
- Work in close coordination with the Provider Services Department to address provider issues, including contract and discount disputes.
- Regularly review all Standard Operating Procedures for the Claim Negotiators to ensure they are up-to-date and accurate.
- Maintain a keen awareness of and ensure strict adherence to Zelis' standards regarding privacy and data protection.
- Bachelor's degree in a related field preferred
- Five years or more experience in healthcare claim negotiations or medical claims processing preferred
- Strong understanding of claims adjudication processes and guidelines
- Demonstrated success in a medical claims contract negotiation setting.
- Knowledge of the full Microsoft Office Suite of products to include, but not limited to, MS Outlook, MS Word, MS Excel, and MS PowerPoint
- A background in medical claims processing, provider billing, medical claim coding is beneficial.
As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.
Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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 TalentAcquisition@zelis.com
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