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Provider Dispute & NSA Adjuster (remote)

3 hours, 50 minutes ago
United States
Full-time
Mid Level
Compliance Manager
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 9

Description

  • Manage provider disputes from intake through final resolution within regulatory timeframes and internal service-level agreements.
  • Research and analyze disputed claims using EOBs, remittance advice, contract terms, benefit language, coordination of benefits, and applicable regulations.
  • Determine whether claim adjustments are warranted and process overturned disputes accurately and in compliance with company policy.
  • Draft clear written responses to providers explaining dispute outcomes and rationale.
  • Serve as the primary point of contact for open negotiation cases under the No Surprises Act and Texas Insurance Code Chapter 1467.
  • Coordinate federal IDR and Texas-specific IDR cases, including offer submissions, supporting documentation, QPA substantiation, and outcome tracking.
  • Apply the correct state or federal dispute framework based on whether a plan is fully insured or self-funded/ERISA.
  • Track IDR outcomes and maintain organized, audit-ready records for regulatory reporting and audits.
  • Analyze dispute trends, denial patterns, and root causes to identify adjudication errors and process gaps.
  • Partner with Claims, Customer Service, Compliance, legal, and finance teams to improve workflows, training, and corrective actions.

Requirements

  • Minimum 3–5 years of experience in a commercial health plan environment with claim adjudication, provider disputes/appeals, and open negotiation and/or Federal IDR case management under the No Surprises Act.
  • Strong experience with Texas open negotiation (Chapter 1467) and working knowledge of Texas Department of Insurance (TDI) requirements, timelines, filing requirements, and IDR processes.
  • Understanding of Texas versus federal dispute frameworks, including when to apply state-regulated (fully insured) versus ERISA/self-funded guidelines.
  • Strong working knowledge of CPT, HCPCS, ICD-10, revenue codes, QPA, and NSA-related regulatory requirements.
  • Ability to analyze complex claim scenarios and apply contract, coding, and policy language to dispute decisions.
  • Strong written communication skills, including experience drafting clear and professional provider responses.
  • Proficiency in claims processing systems, dispute/appeals management platforms, and basic data analysis tools such as Excel.
  • Associate or bachelor's degree in Healthcare Administration, Business, or a related field, or equivalent experience, preferred.
  • Professional certification such as CPC, CPB, or similar, preferred.
  • Experience with FAIR Health, Cotiviti, or similar benchmarking tools used in QPA or payment dispute contexts, preferred.
  • Prior experience developing call center training materials or conducting staff training, preferred.
  • Knowledge of additional state-specific prompt pay requirements beyond Texas, preferred.
  • Must reside in the United States in the Eastern or Central time zone.
  • Must have a dedicated private work area and secure access to high-speed internet for remote work.

Benefits

  • Competitive salary.
  • Comprehensive health, dental, and vision insurance, plus life and disability coverage.
  • Retirement savings plan with company match.
  • Generous time off and vacation.
  • Professional development opportunities.
  • Flexible work environment with remote work.
  • Companywide remote work setup.

Interested in this position?

Apply directly on the company website

Apply Now

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