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Provider Dispute & Adjustment Specialist

1 week, 5 days ago
United States
Full-time
Mid Level
Operations Specialist
Operations
Salesforce
Apply Now
Evry Health

Evry Health

Evry Health is a modern health insurance company that prioritizes delivering great benefits at affordable prices. They offer a unique approach to health insurance by focusing on making members healthier and happier through personalized care from a dedi...

Insurance
11-50
Founded 2017
$7M raised
View All Jobs 3

Description

  • Manage provider disputes from intake through final resolution while meeting regulatory timeframes, state prompt-pay requirements, and internal SLAs.
  • Review dispute submissions for completeness, identify deficiencies, and communicate needed corrections to providers.
  • Research disputed claims using EOBs, remittance advice, claim history, COB records, eligibility data, provider contracts, fee schedules, and benefit language.
  • Analyze claim discrepancies, determine root causes, and decide whether original payment decisions should be upheld, reversed, or modified.
  • Apply coding and billing knowledge, including CPT, HCPCS, ICD-10, revenue codes, modifiers, and fee schedules, to evaluate disputed charges.
  • Initiate and process claim adjustments and remediation, including bulk adjustments when systemic errors are identified.
  • Draft clear written determinations, acknowledgment letters, resolution letters, and reconsideration notices for provider communication.
  • Document dispute activity, adjustment actions, rationale, and outcomes in case management systems for audit readiness and reporting.
  • Identify trends in disputes and payment errors and recommend process improvements, corrective actions, and training opportunities.
  • Collaborate with Claims, Compliance, Legal, Customer Service, Provider Relations, and leadership to resolve issues and improve workflows.

Requirements

  • 3–5 years of experience in a commercial health plan, managed care organization, or TPA environment with responsibility for provider disputes, claim adjustments, or provider appeals.
  • Experience 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.
  • Understanding of provider contract terms, benefit plan language, and reimbursement methodologies.
  • Excellent written communication skills with the ability to draft professional provider-facing correspondence and determination letters.
  • Strong research, investigative, analytical, and critical-thinking skills with the ability to synthesize information from multiple sources.
  • Ability to interpret complex or ambiguous provider requests and produce complete, well-supported responses.
  • Highly organized and detail-oriented with the ability to manage a high-volume caseload and competing deadlines.
  • Proficiency with claims processing systems, case management platforms such as Salesforce, and Microsoft Office Suite, especially Excel and Word.
  • Working knowledge of applicable state and federal regulations, including ERISA, state prompt-pay laws, and Texas Department of Insurance requirements.
  • Associate or Bachelor’s degree in Healthcare Administration, Business, Health Information Management, or a related field, or equivalent professional experience (preferred).
  • Professional certification such as CPB, CPC, Certified Claims Adjuster, or similar credential (preferred).
  • Experience with multiple lines of business, including commercial fully insured, self-funded ERISA plans, and/or individual/group products (preferred).
  • Knowledge of Texas-specific prompt-pay statutes and TDI regulatory requirements (preferred).
  • Experience with Coordination of Benefits, subrogation, and eligibility-related dispute scenarios (preferred).
  • Familiarity with benchmarking and repricing tools used in payment analysis (preferred).

Benefits

  • $65,000 to $70,000 annual salary.
  • Fully remote work arrangement.
  • Standard Monday through Friday, 9:00 AM to 5:00 PM CST schedule.
  • Opportunity to work with a major health insurance organization backed by Globe Life.
  • Occasional schedule flexibility to meet regulatory response deadlines.

Interested in this position?

Apply directly on the company website

Apply Now

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