Claims Repricing Director

Job Description: The Claims Repricing Director is responsible for overseeing the repricing operations, client implementations, and product management for all repricing-related applications. This role works closely with internal teams, external vendors, and clients to ensure seamless integration, accurate claim pricing, and optimal operational performance. The Claims Repricing Director will leverage their technical expertise and leadership skills to drive efficiency, maintain compliance, and enhance client satisfaction. Roles & Responsibilities: • Lead and manage technical implementation for repricing clients, ensuring timelines and quality standards are met with the HCH implementation team. • Work collaboratively with our new Third-Party Administrator (TPA) implementation team as required for repricing clients. • Provide technical expertise in Electronic Data Interchange (EDI) processes. • Utilize reporting and analytics tools, including Power BI, Power Pivot, and Excel, to generate insights and performance metrics. • Administer and maintain MS SQL Server 2008/2012/2016 databases related to claims processing. • Oversee the processing and repricing of claims in alignment with the reference-based pricing (RBP) model, ensuring accuracy, regulatory compliance, and operational efficiency throughout the claims lifecycle. • Manage claim flow process for all clients including network hierarchy set up and appropriate claim flow for out-of-network repricing. • Work with software applications such as Move It and Pilotfish for 837 data consumption. • Collaborate with internal stakeholders to identify process improvements and implement solutions to enhance efficiency and accuracy. • Act as a liaison between internal departments, clients, and vendors to resolve issues and ensure smooth operations. Key Performance Indicators (KPI’s): • Timeliness and accuracy of new client and TPA implementations. • Compliance with vendor contractual agreements and Client satisfaction. • System uptime and performance metrics. • Accuracy of invoicing and budget adherence. • Reporting and analytics. Educational and Qualification Requirements: • Bachelor’s degree in Business, Information Technology, or a related field preferred. • Minimum of 5 years of experience in claims repricing, healthcare operations, or a related field. • Strong knowledge of EDI processes. • Proficiency with MS SQL Server 2008/2012/2016 preferred. • Experience with BI tools such as Power BI, Power Pivot, and Excel. • Familiarity with Move It and Pilotfish for 837 data consumption. • Excellent written and verbal communication skills. • Ability to work independently with minimal supervision. • Exceptional attention to detail and organizational skills. • Confident, assertive, and collaborative team player. • Demonstrated ability to manage multiple projects and deadlines effectively. This position is available for remote work for candidates located out of state. Local candidates will be expected to work onsite in the office. Company Overview: Great Place to Work Certified Healthcare Highways is redefining employer-sponsored healthcare by challenging traditional networks and introducing competition, flexibility, and cost efficiency to the marketplace. As a leader in high-performance networks (HPNs), we specialize in medical provider network services. We partner with high-quality providers, third-party administrators, payors, consultants, and employers to deliver tailored network solutions. Our approach expands access, drives down costs, and optimizes health plan benefits, ensuring better healthcare quality for businesses and their employees. We foster a collaborative, innovative, and inclusive workplace where creative and analytical thinkers thrive. At Healthcare Highways, candor, integrity, and teamwork are at the core of everything we do. We invest in our employees' growth and professional development by offering competitive compensation, career advancement opportunities, and a strong commitment to work-life balance. A career at Healthcare Highways means being part of a forward-thinking organization transforming healthcare. If you're passionate about impacting employers, providers, and the communities we serve, we invite you to join our mission. Explore opportunities and join our team today at Healthcare Highways Careers. Apply Job!