We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary:
The Manager, Out-of-Network Claims Negotiation is responsible for leading the strategy, operations, and performance of the claims negotiation team supporting both No Surprises Act (NSA) claims and elective out-of-network reimbursement negotiations. This role oversees a team of negotiators focused on achieving fair, compliant, and cost-effective claim resolutions while balancing provider relations, regulatory requirements, client expectations, and member experience.
What You'll Do:
- Serve as the subject matter expert on out-of-network reimbursement methodologies, No Surprises Act (NSA) regulations, and negotiation best practices, providing strategic guidance and expertise across the organization.
- Lead daily negotiation operations while partnering closely with Product, Operations, Compliance, Analytics, and Client teams to enhance negotiation strategies, support product development, drive operational excellence, and ensure compliance with federal and state regulations.
- Monitor team performance, coach and develop negotiation talent, analyze negotiation outcomes and market trends, identify process improvement opportunities, and help shape the ongoing evolution of negotiation products and services.
- Drive measurable financial savings, foster strong provider relationships and engagement, and contribute to the achievement of key business growth and organizational objectives.
Required Qualifications
- 5+ years of healthcare claims, reimbursement, provider contracting, network management, or negotiation experience.
- 2+ years of leadership experience managing teams and operational performance.
- Demonstrated expertise in the No Surprises Act (NSA), out-of-network reimbursement methodologies, provider billing practices, and healthcare claims adjudication, with the ability to interpret complex regulations, evaluate claim and reimbursement disputes, guide negotiation strategies, ensure compliance, and drive favorable financial and operational outcomes.
- 2+ years of experience working with payers, providers, healthcare networks, or managed care organizations.
- Demonstrated ability to lead cross-functional initiatives and support product development efforts.
- Strong analytical, communication, negotiation, and problem-solving skills.
- Proficiency in interpreting claims data, performance metrics, and reimbursement trends.
- Proficiency in Microsoft Office Suite (Excel, PowerPoint, Word, and Outlook).
Preferred Qualifications
- Experience working with Centers for Medicare & Medicaid Services (CMS) regulations, reimbursement guidelines, and healthcare compliance requirements.
- Knowledge of the No Surprises Act (NSA) and out of network reimbursement methodologies.
Education
- Bachelor's degree or equivalent combination of education and healthcare industry experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$66,330.00 - $145,860.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
CVS Health Boston, Massachusetts, USA Office
Boston, Massachusetts, United States, 02114
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