Claims representative Jobs in St Louis, MO

Senior Director, Claims Pricing & Revenue

At Zelis, we Get Stuff Done. So, let's get to it!

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts driving real, measurable results for clients.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

Position Overview

As part of the Pricing Solutions division, this role leads strategic initiatives that improve the performance, efficiency, scalability, and future readiness of the Claims Pricing & Revenue organization. This role works closely with Claims Pricing & Revenue leadership to translate business priorities into actionable plans, strengthen operating performance, and identify opportunities to modernize claims pricing, repricing, negotiation, and related revenue operations. Initially serving as a senior individual contributor, the Senior Director leads complex, cross-functional work through influence, subject-matter expertise, and strong execution. The role may lead a team in the future as the organization's transformation agenda and capabilities expand. The Senior Director partners across Operations, Product, Technology, Analytics & Insights, Finance, Networks, Client Services and other key stakeholders to improve how work is performed and measured. The role will be particularly focused on identifying and implementing AI, automation, globalization, and workflow opportunities that improve productivity, quality, turnaround time, cost-to-serve, and margin performance.

What You'll Do:

Strategic Initiatives and Functional Transformation

• Lead high-priority initiatives that advance the Claims Pricing & Revenue strategy and improve the organization's long-term performance.
• Translate strategic priorities into practical roadmaps, work plans, milestones, ownership, and measurable outcomes.
• Identify opportunities to simplify work, reduce fragmentation, eliminate unnecessary handoffs, and improve coordination across claims pricing, repricing, and negotiation functions.
• Evaluate current operating practices and recommend changes that improve scalability, consistency, quality, and margin performance.
• Lead initiatives that span multiple products, operational teams, systems, or stakeholder groups.
• Surface risks, dependencies, resource requirements, and tradeoffs to support leadership decisions and prioritization.

AI, Automation and Operational Innovation

• Partner key stakeholders and operational leaders to identify high-value AI, automation, and workflow opportunities.
• Assess opportunities based on operational impact, feasibility, capacity released, quality improvement, cost, risk, and expected return.
• Develop implementation plans that clearly define the business need, expected outcome, workflow change, resource requirements, adoption approach, and performance measures.
• Help move initiatives from concept through implementation by coordinating the appropriate operational, product, technology, and business stakeholders.
• Identify repeatable capabilities that can be standardized or scaled across claims pricing and revenue teams.
• Support globalization strategies responsibly while maintaining quality, regulatory compliance, and client performance.
• Monitor adoption and business results to ensure implemented solutions deliver the intended value.

Claims Pricing and Revenue Operations Optimization

• Develop an end-to-end understanding of claims pricing, repricing, prepay and post-pay negotiations, revenue realization, and associated operational workflows.
• Identify opportunities to improve throughput, accuracy, cycle time, quality, workforce utilization, and cost-to-serve.
• Partner with operational leaders to address performance gaps, bottlenecks, duplicative work, and inconsistent processes across teams.
• Recommend operating-model, workflow, resource, or capability changes that enable the function to scale efficiently.
• Ensure operational improvements support the commercial, financial, regulatory, and client commitments of the business.
• Support evaluation of which activities should be automated, standardized, centralized, globalized, redesigned, or discontinued.

Operational Performance, KPIs and Feedback Loops

• Partner with Analytics & Insights and Process Excellence to define the KPIs required to manage Claims Pricing & Revenue performance.
• Establish measures for productivity, throughput, quality, cycle time, automation adoption, negotiation outcomes, resource utilization, cost-to-serve, and other relevant business results.
• Help to ensure capacity models are developed to support the operations of the business.
• Ensure leaders have clear, reliable dashboards and performance insights that support timely decisions.
• Analyze performance trends and identify emerging risks, recurring issues, and opportunities for improvement.
• Establish feedback loops among Business Operations, Product Strategy, Product Delivery, Technology, Finance, and Process Excellence.
• Use operational findings to inform product enhancements, technology priorities, process changes, workforce plans, and future strategic initiatives.
• Measure the impact and return of operational changes and recommend adjustments where expected benefits are not being achieved.

Cross-Functional Leadership and Partnership

• Serve as a strategic advisor to Claims Pricing & Revenue leadership on operating performance, transformation priorities, and organizational opportunities.
• Lead cross-functional initiatives without relying on direct reporting authority.
• Build alignment across teams with different priorities, operating models, and areas of expertise.
• Partner with Finance on profitability analysis, financial implications, capacity investments, cost-to-serve, and business cases while preserving Finance's ownership of product pricing and financial validation.
• Partner with Product Strategy to communicate operational needs, recurring client themes, and capability opportunities that may affect product direction.
• Partner with Product Delivery and Technology to translate approved priorities into implementable solutions.
• Partner with Process Excellence on work intake, prioritization, process redesign, adoption, and measurement.
• Communicate progress, risks, decisions, and results clearly to senior leaders and other stakeholders.

Client Escalations

• Lead or coordinate resolution of select complex and high-impact client escalations.
• Bring together the appropriate operational, client, product, technical, compliance, network, and financial stakeholders.
• Clarify accountability, action plans, timelines, communications, and decision points.
• Distinguish immediate client resolution from longer-term systemic improvement.
• Identify recurring escalation themes and use them to inform process, product, training, or operating-model changes.
• Ensure resolutions are sustainable and do not create unnecessary manual work or operational risk.

Organizational Capability and Workforce Readiness

• Identify the skills, roles, capacity, and operating capabilities required to execute the future Claims Pricing & Revenue strategy.
• Support workforce planning and recommendations related to upskilling, reskilling, globalization, role redesign, and future hiring.
• Develop repeatable approaches, tools, and frameworks that improve how strategic initiatives are managed across the function.
• Support change adoption by helping leaders and teams understand new workflows, responsibilities, performance expectations, and measures.
• If the role develops into a people-leadership position, build and lead a high-performing team focused on strategic initiatives and functional transformation.
• Must be available to travel 25% - 50% as required to meet business needs.

What You'll Bring to