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Provider Dispute & NSA Adjuster

10 hours, 1 minute 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 2

Description

  • Manage provider disputes from intake through final resolution in accordance with regulatory timeframes and internal SLAs.
  • Conduct thorough research and analysis of disputed claims, including EOBs, remittance advice, contract terms, benefit language, coordination of benefits, and applicable federal and state regulations.
  • Evaluate documentation to determine whether claim adjustments are warranted and ensure accurate processing when disputes are overturned.
  • Draft clear, well-supported written responses to providers explaining rationale for upheld or adjusted decisions.
  • Serve as primary point of contact and manage all phases of open negotiation cases under the No Surprises Act and Texas Insurance Code Chapter 1467, including notice handling, negotiation of payment amounts, and documenting outcomes.
  • Coordinate submission and management of Federal IDR cases, including preparation of offer submissions, supporting documentation, and QPA substantiation.
  • Manage Texas-specific IDR cases to ensure compliance with state-mandated timelines, notice requirements, and offer submissions under Chapter 1467.
  • Track and monitor IDR outcomes at federal and state levels, maintain organized audit-ready records, and collaborate with legal, compliance, and finance on submissions.
  • Analyze dispute trends, root causes, and denial patterns to identify adjudication errors and process gaps, and translate findings into actionable recommendations for leadership.
  • Partner with Claims Operations and Customer Service/Call Center leadership to implement corrective actions, develop training materials, and deliver training based on dispute trends and knowledge gaps.

Requirements

  • 3–5+ years of experience in a commercial health plan environment including 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 distinctions between state-regulated (fully insured) and federally regulated (self-funded/ERISA) plans and when each dispute framework applies.
  • Working knowledge of CPT, HCPCS, ICD-10, and revenue codes, as well as 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 with experience drafting clear and professional provider responses.
  • Proficiency with claims processing systems, dispute/appeals management platforms, and basic data analysis tools (Excel or similar).
  • Must reside in the United States within Eastern or Central time zones and be able to work standard business hours (company hours weekdays 9–5 CST) with occasional flexibility to meet regulatory deadlines.
  • Preferred: Associate or Bachelor’s degree in Healthcare Administration, Business, or related field (or equivalent experience); professional certifications such as CPC or CPB; experience with FAIR Health, Cotiviti, or similar benchmarking tools; prior experience developing call center training or conducting staff training; knowledge of additional state-specific prompt pay requirements.

Benefits

  • Competitive salary
  • Comprehensive health, dental, and vision insurance, plus life and disability coverage
  • Retirement savings plan with company match
  • Generous time off/vacation
  • Professional development opportunities
  • Flexible, remote-first work environment (company-wide remote)

Interested in this position?

Apply directly on the company website

Apply Now

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