Claim Settlement Specialist

Zelis Healthcare, LLC
United States, Missouri, St. Louis
May 21, 2025
At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience for all by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts-driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview The Claims Settlement Specialist supports claim settlement with providers through post payment negotiation. The Regulated Claims Settlement Specialist will be responsible for handling provider disputes and formal appeal processes under Federal and State regulated settlement programs. During this process, the Regulated Claims Settlement Specialist must understand: (1) the procedures billed on the claim/bill; (2) the estimate of the fair value of the payment that was remitted to under the applicable Federal or State law, location/facility/provider comparisons, and Zelis' proprietary evaluation software; (3) identify negotiation points for that particular provider, or service, if payment is not accepted, as is; and, when required or reasonable under the applicable law, negotiate an acceptable payment settlement within the required timeframe for the applicable Federal or State law. What you'll do: Providing a formal response to providers who have submitted pricing disputes through formal settlement or arbitration processes Evaluating supporting documentation or arguments presented by providers to determine if a settlement above the applied pricing is warranted Answering calls from providers who are questioning the paid amount on any claim(s) handled by Zelis for payor. Returning all calls within one business day of receiving the call. Address newly assigned work within 48 hours of receipt. Creating payment negotiation documents using proprietary programs and transmitting those via fax, e-mail, or other methods. Documenting stages of process and outcome of post payment negotiation in custom database. Analyzing medical claims and applicable federal or state laws and being able to discuss them with specific providers. Negotiating claims within applicable federal and state law parameters and timeframes as required. Performs other related responsibilities as assigned. What you'll bring to Zelis: Three years or more experience in healthcare collections, billing or claim negotiations Demonstrated success in a sales or contract negotiations 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 healthcare collections, provider billing, retail or sales is beneficial. 4-year college degree preferred. Maintains confidentiality and handle sensitive material. Demonstrates solution orientation; takes initiative when resolving challenges or improving process. Displays self-motivation and the ability to work independently and as a team. Demonstrates ability to balance and prioritize workload from various service units and individuals in a fast-paced environment. Demonstrated motivation to provide fast, accurate and complete customer service at all times to employees, external contacts, and management. Recognizes deviations from expected observations. Calls attention to results that require analysis. Completes work in a timely fashion and in accordance with established deadlines. Alerts leadership, in advance, if deadlines are unable to be achieved. Ability to effectively communicate with active listening and persuasive speaking skills. Strong analytical, public speaking and negotiation skills. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified 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 welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support 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. Disclaimer We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law. The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.