Director of Revenue Optimization and Operations

Role Description

The Director of Revenue Optimization and Operations is a strategic leadership role responsible for overseeing high-impact initiatives related to the No Surprises Act (NSA), Plan Administrator engagement, Summary Plan Description (SPD) analysis, payer negotiations, and department-wide learning and training sessions. This individual will drive process development, optimize reimbursement outcomes, and ensure regulatory compliance across all related workflows.

This role requires a deep understanding of out-of-network billing, federal and state regulations, ERISA plans, and dispute resolution strategies. The Director will lead cross-functional initiatives, develop scalable processes, and mentor teams to maximize efficiency and revenue recovery.

Essential Responsibilities

• NSA (No Surprises Act) Ownership
  • Oversee end-to-end NSA workflow, including IDR (Independent Dispute Resolution) submissions and outcomes
  • Develop and implement strategies to improve NSA success rates and turnaround times
  • Monitor regulatory updates and ensure organizational compliance with federal and state NSA requirements
  • Identify trends, payer behaviors, and opportunities for escalation or optimization
  • Collaborate with legal, compliance, and billing teams on dispute strategies
• Plan Administrator & Letter Strategy
  • Direct development and execution of Plan Administrator outreach strategies
  • Oversee creation and refinement of demand letters, appeals, and escalation templates
  • Ensure all communications are compliant, strategic, and aligned with ERISA guidelines
  • Track response rates, escalation success, and financial outcomes
• SPD (Summary Plan Description) Oversight
  • Lead analysis and interpretation of SPDs to identify reimbursement opportunities
  • Develop internal workflows for extracting key plan provisions (UCR, reimbursement methodology, appeal rights, etc.)
  • Train and guide teams on SPD utilization for appeals and negotiations
  • Partner with legal/compliance teams to ensure accurate interpretation and application
• Negotiations & Payer Strategy
  • Lead high-level payer negotiations for out-of-network claims and settlements
  • Develop negotiation frameworks and playbooks for team utilization
  • Analyze payer trends to inform negotiation tactics and escalation pathways
  • Maximize reimbursement while maintaining compliance with all applicable regulations
• Department-Wide Learning & Training
  • Design and lead recurring RCM-wide learning sessions for all staff across all Revenue Cycle Management (RCM) departments
  • Assist with onboarding across all backend RCM departments by coordinating role-based training plans
  • Develop and maintain RCM-wide training materials (playbooks, job aids, templates, and SOPs)
  • Identify skill gaps using cross-department performance trends, QA findings, payer feedback, and operational metrics
  • Establish an RCM-wide training cadence, attendance expectations, and effectiveness measures
  • Coach managers and SMEs to deliver training content and reinforce best practices
• Medical Records
  • Partner with the Medical Records to streamline retrieval of documentation needed for appeals, NSA/IDR submissions, audits, and payer negotiations
  • Establish and maintain SOPs, service-level expectations, and escalation pathways for urgent record requests
  • Ensure documentation packages meet payer requirements while supporting privacy and compliance standards
  • Collaborate on tracking metrics and reporting to leadership to improve throughput and financial outcomes
• Process Development & Leadership
  • Build, implement, and continuously improve workflows
  • Establish KPIs, dashboards, and reporting to track performance and outcomes
  • Lead, mentor, and develop team members across NSA, collections, and appeals functions
  • Collaborate with executive leadership on strategic initiatives and organizational growth
  • Perform other duties and special projects as assigned to support departmental and organizational priorities

Qualifications

• 5-10+ years of experience in healthcare revenue cycle, with strong focus on out-of-network billing
• Deep expertise in No Surprises Act (NSA), IDR process, and payer dispute resolution
• Strong knowledge of ERISA, Plan Administrator processes, and SPD interpretation
• Proven experience in payer negotiations and complex collections strategies
• Demonstrated ability to build teams, processes, and scalable workflows
• Excellent analytical, strategic thinking, and leadership skills
• Strong communication skills, particularly in written appeals and negotiation scenarios

Requirements

• Provide coaching, performance management, and workforce development for team members

Benefits

• 401(k) matching
• Medical, Dental & Vision
• Paid Time Off
• Sick Time
• Paid Holidays