evry-health - Provider Dispute & Adjustment Specialist

Remote - CT (Central)1w ago

Requirements

• Minimum 3–5 years of experience in a commercial health plan, managed care organization, or third-party administrator (TPA) environment, with direct responsibility for provider dispute resolution, claim adjustments, and/or provider appeals. • Demonstrated experience reviewing and resolving provider payment disputes, billing reconsiderations, and claim adjustment requests from intake through final written determination. • Strong working knowledge of claim adjudication principles, including CPT, HCPCS, ICD-10, revenue codes, modifiers, and fee schedule application. • Solid understanding of provider contract terms, benefit plan language, and reimbursement methodologies, with the ability to apply this knowledge to dispute resolution decisions. • Exceptional written communication skills, including demonstrated ability to draft clear, professional, and thorough provider-facing correspondence and determination letters. • Strong research and investigative skills, including the ability to independently gather, analyze, and synthesize information from multiple sources to reach well-supported conclusions. • Ability to interpret complex and sometimes ambiguous provider requests, identify the underlying issue(s), and formulate a complete and appropriate response. • Strong analytical and critical-thinking skills with the ability to evaluate claim scenarios, apply policy and contract language, and make sound, independent determinations. • Highly organized, detail-oriented, and capable of managing a high-volume caseload with competing deadlines while maintaining accuracy and compliance. • Proficiency in claims processing systems, case management platforms (e.g., Salesforce), and Microsoft Office Suite (particularly Excel and Word). • Working knowledge of applicable state and federal regulations governing provider disputes and claims, including ERISA, state prompt-pay laws, and TDI requirements. • Associate or Bachelor’s degree in Healthcare Administration, Business, Health Information Management, or a related field (or equivalent professional experience). • Professional certification such as Certified Professional Biller (CPB), Certified Professional Coder (CPC), Certified Claims Adjuster, or similar credential. • Experience with multiple lines of business, including commercial fully insured, self-funded ERISA plans, and/or individual/group market products. • Knowledge of Texas-specific prompt-pay statutes and TDI regulatory requirements. • Prior experience developing or delivering training materials related to provider billing, dispute processes, or claims adjudication. • Experience with Coordination of Benefits (COB), subrogation, and eligibility-related dispute scenarios. • Familiarity with benchmarking and repricing tools used in payment analysis contexts. • ## Core Competencies • Analytical Thinking • Breaks down complex claim scenarios to identify root cause and appropriate resolution. • Research & Investigation • Independently sources, evaluates, and synthesizes information to support sound decisions. • Written Communication • Produces clear, professional, and well-reasoned written determinations and correspondence. • Regulatory Knowledge • Applies current knowledge of state and federal rules governing provider claims and disputes. • Attention to Detail • Consistently produces accurate work product with minimal errors under deadline pressure. • Navigates changing regulatory environments and shifting priorities with professionalism. • Cross-Functional Collaboration • Partners effectively with Claims, Compliance, Legal, and Provider Relations teams. • ## Work Environment • This is a fully remote position. Candidates must reside in the United States within the Central (CST) or Eastern (EST) time zone. • Standard business hours are Monday through Friday, 9:00 AM – 5:00 PM CST, with occasional flexibility required to meet regulatory response deadlines. • Must maintain a dedicated, private workspace that is separate from other living areas and supports the secure handling of confidential information. • Must have a reliable high-speed internet connection. • All company-sensitive documents must be kept secure and handled in accordance with Evry Health data privacy and security policies.

Responsibilities

• Provider Dispute Intake & Management • Manage provider disputes from initial intake through final resolution, ensuring adherence to regulatory timeframes, state prompt-pay requirements, and internal SLAs. • Review and validate all incoming dispute submissions to confirm completeness; identify and communicate deficiencies to providers in a timely and professional manner. • Accurately log, track, and maintain dispute inventories within Salesforce or applicable case management systems, ensuring real-time case status visibility. • Prioritize and manage a high-volume caseload while maintaining accuracy, thoroughness, and compliance with established turnaround standards. • Identify when cases require escalation to senior staff, management, legal, or other internal departments and facilitate appropriate handoffs. • Research, Investigation & Analysis • Conduct thorough, independent research into disputed claims by reviewing EOBs, remittance advice, claim histories, coordination of benefits (COB) determinations, eligibility records, provider contracts, fee schedules, and applicable benefit language. • Investigate root causes of payment discrepancies, including contract misapplication, coding errors, system configuration issues, benefit plan misinterpretation, and eligibility discrepancies. • Evaluate new information and documentation submitted by providers against the original claim decision. • Apply knowledge of CPT, HCPCS, ICD-10, revenue codes, and billing guidelines to evaluate the validity of disputed charges and determine appropriate payment outcomes. • Analyze and interpret complex provider requests, identify the specific issue(s) raised, and determine the most appropriate and complete course of action for resolution. • Review applicable state and federal regulations, internal policies, and provider contract terms to support well-reasoned dispute determinations. • Gather, organize, and evaluate all pertinent documentation — including claim history, supporting provider correspondence, and system notes — to build a complete case record prior to issuing a determination. • Claim Adjustments & Payment Corrections • Initiate and process claim adjustments for disputes determined to be valid, ensuring corrections are applied accurately and completely in claims processing systems. • Remediate impacted claims identified through the dispute process, including bulk adjustments when systemic errors are identified. • Verify that adjusted claims are reprocessed in accordance with the correct contract, benefit, and coding guidelines, and that resulting payments are accurately issued. • Validate adjustment outcomes post-processing and communicate finalized results to providers in a clear and timely manner. • Document all adjustment actions, rationale, and outcomes in the case management system for audit-readiness and regulatory reporting. • Provider Communications & Written Correspondence • Draft clear, professional, and well-supported written responses to providers for all dispute determinations — both upheld and overturned — ensuring that all points raised by the provider are directly and thoroughly addressed. • Compose acknowledgment letters, resolution letters, and reconsideration notices in accordance with regulatory requirements and internal communication standards. • Ensure all written correspondence is accurate, concise, free of jargon, and appropriate for the intended audience, whether a billing department, practice manager, or hospital administrator. • Maintain consistent, professional communication throughout the dispute lifecycle, including follow-up correspondence when additional information is requested. • Serve as a knowledgeable resource for providers navigating the dispute and adjustment process, responding to inquiries in a timely and informative manner. • Trend Analysis & Process Improvement • Analyze dispute and adjustment trends to identify patterns in claim adjudication errors, billing code misapplication, contract misinterpretation, or system configuration issues. • Partner with the VP of Operations to develop and implement corrective action plans based on findings from dispute and adjustment activity. • Translate dispute data and root cause analysis into actionable insights and present recommendations to leadership to improve workflows, reduce error rates, and strengthen the overall claims process. • Collaborate with Customer Service leadership to identify training gaps and support the development of educational materials related to billing, coding, claim submission, and dispute processes for the CSRs. • Contribute to the development and maintenance of department policies, procedures, and job aids. • Documentation & Regulatory Compliance • Maintain detailed, audit-ready case documentation for all disputes, adjustments, within Salesforce or the designated case management platform. • Ensure all dispute activity complies with applicable state and federal regulations, including ERISA requirements, state prompt-pay statutes, Texas Department of Insurance (TDI) rules, and internal policies. • Support internal and external audits by providing complete and organized dispute records, resolution documentation, and reporting as requested. • Stay current on regulatory changes affecting provider dispute resolution, claims payment requirement processes at both the federal and state level. • Adhere to all privacy, confidentiality, and data security requirements in the handling of provider and member information.