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About the Role
IPRO is seeking a Dispute Resolution Specialist to administer and adjudicate healthcare payment disputes under the federal No Surprises Act Independent Dispute Resolution (IDR) process. You will review and evaluate disputes between healthcare providers, facilities, and health plans to determine appropriate reimbursement amounts in accordance with applicable federal laws, regulations, guidance, and IDR requirements. This role requires acute critical thinking and analytical skills to conduct impartial, evidence-based reviews and render binding determinations.
Responsibilities
- Independently manage healthcare payment disputes from case assignment through final determination using the CMS Federal IDR Portal and other designated systems.
- Evaluate final payment offers, supporting documentation, and written arguments submitted by providers, facilities, and health plans.
- Ensure all submissions comply with applicable federal IDR requirements and procedural standards.
- Assess Qualifying Payment Amounts (QPA), provider training and experience, patient acuity, complexity of services, market share, prior contracted rates, and other permissible factors outlined in federal regulations.
- Review medical records, itemized bills, clinical documentation, and related materials to determine the appropriateness of billed services and support evidence-based payment determinations.
- Research and analyze applicable federal statutes, regulations, guidance, payer information, fee schedules, and relevant contractual data to support dispute resolution decisions.
- Prepare clear, objective, and well-supported written determinations that explain the rationale for payment selections and comply with federal IDR requirements.
- Document status of dispute resolutions accurately.
- Ensure all dispute reviews and determinations are conducted impartially and in accordance with No Surprises Act regulations, CMS guidance, established procedures, and applicable timelines.
- Communicate effectively with clients, providers, and internal departments to resolve issues.
Requirements
- Familiarity with healthcare claims and appeals processes.
- Excellent communication skills.
- Ability to interact with healthcare providers and commercial payors, or managed care organizations.
- Ability to work independently or as part of a team.
- Comfortable in a fast-paced environment with strong attention to detail.
Skills
- Acute critical thinking
- Analytical skills
- Problem-solving skills
- Data visualization
- Report creation
- Translating data into actionable recommendations
Experience Level
- 4 years of experience in medical billing, auditing, or claims review, appeals or dispute resolution in healthcare or insurance industries (with Associate's degree)
- 3 years of experience in medical billing, auditing or claims review, appeals or dispute resolution in healthcare or insurance industry (with Bachelor's degree)
Education Level
- Associate's degree
- Bachelor's degree
Salary/Compensations
- $75,000.00 – $80,000.00
About the Company
- IPRO is an Equal Opportunity Employer.
Equal Opportunity
- All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or military status, or any other category protected under applicable law.