The Role
The Director of Out of Network Solutions leads departmental planning and execution, ensuring operational efficiency and management of staff, budgets, and strategic goals within the healthcare sector.
Summary Generated by Built In
Job Summary & Responsibilities
JOB SCOPE: The Director works independently and exercises significant discretion and independent judgment. The incumbent provides input to make critical business decisions, including staffing and process improvement, and impacts day-to-day operations through the oversight of claim resolution and providing direction to staff on individual cases. The incumbent manages and impacts overall department budgets as well as team profitability. The incumbent operates with considerable latitude for unreviewed decisions and uses an extensive range of knowledge to complete job responsibilities. The incumbent manages staff and helps provide thorough and appropriate responses to clients and providers to meet the goals of the department. This role has the authority to recommend and implement appropriate policies, procedures, and controls to assure compliance with applicable contractual provisions, regulations, and legislation. This position manages others and has the authority for all HR actions (hiring, firing, discipline, training, etc). Preferred Qualifications
JOB SUMMARY: This position is responsible for planning, directing, and coordinating all aspects of the department to ensure savings preservation and growth, service of all assigned business clients, and the effective communication of the Company's solutions to existing and prospective business partners. This job is responsible for providing the type of leadership, management, and vision necessary to achieve short and long-range business goals and to grow the business unit as well as ensuring operating efficiency. The Director is responsible for directing all facets of the department including staffing, goal setting, budget compliance, product evaluation and enhancement, and policies/procedures to ensure smooth and efficient operations. This job is also responsible for strategic planning and budget decisions.
JOB ROLES AND RESPONSIBILITIES:
1. Direct management of performance to ensure competent staff delivers quality results. This includes training, mentoring, motivating, and overseeing staff performance.
2. Develop, implement, and manage both short and long term goals, objectives, policies, and procedures based on current and future trends. Stay abreast of industry and/or customer changes and communicate as appropriate.
3. Compile, analyze, and report on trends to include performance improvement initiatives and exceptional client delivery.
4. Oversight and development of operational relationships and performance for both client and provider.
5. Review referral trends on a monthly basis referral trends to identify opportunities for performance improvement and operational efficiencies.
6. Manage departmental and team budgets including expenses, cost containment, and profitability.
7. Provide direction and guidance to other levels of management, through delivery of instructions and direction to staff on individual cases and the creation and distribution of goals and standards to subordinates regularly.
8. Act as a subject matter expert internally for the Team and other departments within the Company.
9. Select, develop, and evaluate staff to ensure the efficient operation of department.
10. Collaborate, coordinate, and communicate across disciplines and departments.
11. Ensure compliance with HIPAA regulations and requirements.
12. Demonstrate Company's Core Competencies and values held within.
13. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned, as necessary.
2. Develop, implement, and manage both short and long term goals, objectives, policies, and procedures based on current and future trends. Stay abreast of industry and/or customer changes and communicate as appropriate.
3. Compile, analyze, and report on trends to include performance improvement initiatives and exceptional client delivery.
4. Oversight and development of operational relationships and performance for both client and provider.
5. Review referral trends on a monthly basis referral trends to identify opportunities for performance improvement and operational efficiencies.
6. Manage departmental and team budgets including expenses, cost containment, and profitability.
7. Provide direction and guidance to other levels of management, through delivery of instructions and direction to staff on individual cases and the creation and distribution of goals and standards to subordinates regularly.
8. Act as a subject matter expert internally for the Team and other departments within the Company.
9. Select, develop, and evaluate staff to ensure the efficient operation of department.
10. Collaborate, coordinate, and communicate across disciplines and departments.
11. Ensure compliance with HIPAA regulations and requirements.
12. Demonstrate Company's Core Competencies and values held within.
13. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned, as necessary.
JOB SCOPE: The Director works independently and exercises significant discretion and independent judgment. The incumbent provides input to make critical business decisions, including staffing and process improvement, and impacts day-to-day operations through the oversight of claim resolution and providing direction to staff on individual cases. The incumbent manages and impacts overall department budgets as well as team profitability. The incumbent operates with considerable latitude for unreviewed decisions and uses an extensive range of knowledge to complete job responsibilities. The incumbent manages staff and helps provide thorough and appropriate responses to clients and providers to meet the goals of the department. This role has the authority to recommend and implement appropriate policies, procedures, and controls to assure compliance with applicable contractual provisions, regulations, and legislation. This position manages others and has the authority for all HR actions (hiring, firing, discipline, training, etc).
JOB REQUIREMENTS (Education, Experience, and Training):
* Minimum Bachelor's degree in healthcare, business, marketing, or related field preferred
* Minimum 7 years experience in the healthcare industry with a minimum of 4 years in a leadership role with people management responsibilities.
* State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification. If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available. When an alternate position is unavailable, other employment actions may be implemented consistent with MultiPlan practice and policy.
* Knowledge of provider billing and collection practices.
* Knowledge of effective negotiations principles.
* Knowledge of commonly used medical coding systems.
* Knowledge of commonly used medical data resources.
* Knowledge of HCFA-1500 and UB-92 medical claim forms.
* Knowledge of Worker's Comp, Auto Medicare, and Government sponsored programs (such as Medicare or Medicaid).
* Communication (verbal and written), managerial, interpersonal, organizational, time management, customer service/sales, problem solving, leadership, strategic, analytical, tactical and execution skills.
* Ability to prioritize and manage time.
* Ability to manage various teams.
* Ability to make decisions using limited or incomplete data.
* Ability to manage multiple projects at the same time.
* Ability to use software, hardware, and peripherals related to job responsibilities, including advanced proficiency with MS Office
* Ability to travel with minimal notice.
As an Equal Opportunity Employer, the Company will provide equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.
* Minimum 7 years experience in the healthcare industry with a minimum of 4 years in a leadership role with people management responsibilities.
* State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification. If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available. When an alternate position is unavailable, other employment actions may be implemented consistent with MultiPlan practice and policy.
* Knowledge of provider billing and collection practices.
* Knowledge of effective negotiations principles.
* Knowledge of commonly used medical coding systems.
* Knowledge of commonly used medical data resources.
* Knowledge of HCFA-1500 and UB-92 medical claim forms.
* Knowledge of Worker's Comp, Auto Medicare, and Government sponsored programs (such as Medicare or Medicaid).
* Communication (verbal and written), managerial, interpersonal, organizational, time management, customer service/sales, problem solving, leadership, strategic, analytical, tactical and execution skills.
* Ability to prioritize and manage time.
* Ability to manage various teams.
* Ability to make decisions using limited or incomplete data.
* Ability to manage multiple projects at the same time.
* Ability to use software, hardware, and peripherals related to job responsibilities, including advanced proficiency with MS Office
* Ability to travel with minimal notice.
As an Equal Opportunity Employer, the Company will provide equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.
Skills Required
- Minimum Bachelor's degree in healthcare, business, marketing, or related field preferred
- Minimum 7 years experience in the healthcare industry
- Minimum 4 years in a leadership role with people management responsibilities
- State licensure certification may be required
- Knowledge of provider billing and collection practices
- Knowledge of effective negotiation principles
- Ability to use software and peripherals related to job responsibilities
Claritev Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Claritev and has not been reviewed or approved by Claritev.
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Leave & Time Off Breadth — Paid time off, paid holidays, and paid parental leave are part of the offering. Flexible schedules expand practical time‑off and scheduling options.
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Healthcare Strength — Medical (PPO and HDHP), dental, vision, and HSA/FSA options are available alongside an EAP and a Noom weight‑management program. These elements indicate broad healthcare coverage with added wellness support.
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Flexible Benefits — Work‑from‑home opportunities and flexible schedules are commonly advertised. Remote work and schedule flexibility are highlighted as positives that can offset cash‑pay concerns for some employees.
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The Company
What We Do
Claritev is an independent and public healthcare technology, data and insights company making healthcare more transparent, fair and affordable for all. We work across the healthcare value chain to expose imbalanced and inefficient pricing practices. Led by deeply experienced analysts, negotiators and innovators, Claritev provides tech-enabled solutions and services fueled by proprietary data from over 40 years of experience. Today, along with machine learning and AI, we utilize a robust enterprise platform to deliver price transparency, improve payment accuracy, and drive more meaningful analytics and decision-making. Through Claritev, providers are able to make data-enabled decisions to optimize their service offerings, market position and ultimately deliver high-quality care. Payors and third-party administrators can deliver greater flexibility and value to plan sponsors. Employers can drive cost-efficient benefit design and patients can finally afford the care they need. By focusing on customized solutions that that improve transparency, affordability and quality for all key players, we’re igniting a more competitive marketplace — one that lowers overall costs while improving quality. Claritev brings the transparency our nation needs to see its way to a better healthcare system.
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