Job Title : Claims Dispute Resolution Analyst
Labor Grade : FLSA : Exempt
Department : Health Fund
Reports To : Interim - Manager, Health Fund Operations
Summary :
Reporting to the Manager of Health Fund Operations on an interim basis, the Claims Dispute Resolution Analyst will be responsible for reviewing healthcare claims flagged under the "lesser of terms" payment principle and managing cases within the Independent Dispute Resolution (IDR) process. This role involves analyzing claims, negotiating equitable reimbursement rates, and ensuring compliance with regulatory requirements, including the No Surprises Act. The Analyst will collaborate with internal teams, healthcare providers, and payers to resolve disputes while maintaining accurate documentation and delivering timely results
Principal Duties and Responsibilities :
Case Review and Analysis
- Conduct thorough review of disputed medical claims to determine the medical necessity of services provided to our members and identify resolution pathways
- Analyze clinical documentation to support or contest payment disputes
- Identify and review cases flagged under the "lesser of terms" payment principle.
- Analyze claim details, including billed charges, payer allowed amounts, and applicable contracts or benchmark rates.
- Collaborate with healthcare providers to obtain necessary clinical information and provide expert clinical insight during negotiations
Negotiation
Initiate and manage rate negotiation discussions with healthcare providers and / or facilities.Leverage data such as industry benchmarks, comparable claims, and cost analysis to propose equitable reimbursement rates.Document all negotiation processes, ensuring transparency and accountability.IDR Process Management
Coordinate the submission of notices and required documentation through various methods of receiptEnsure compliance with federal regulated 30-day open negotiation period and timelines for IDR requests.Manage the workflow of IDR cases from initiation through final resolution.Data Entry and Documentation
Accurately input case details, clinical data, and communications into internal system.Maintain records of all correspondence, decisions, and outcomes related to IDR cases.Ensure all documentation is complete and compliant with federal regulations.Collaboration and Communication
Coordinate with internal teams, including billing, compliance, and legal, to gather necessary documentation for negotiations.Serve as a liaison between providers and payers, facilitating efficient and amicable resolutions.Communicate outcomes effectively to all stakeholders, including patients when necessary.Compliance
Maintain up-to-date knowledge of regulations governing claims and reimbursement, particularly around "lesser of terms" and balance billing.Ensure all actions and submissions are in full compliance with federal regulatory requirements.Support the maintenance of a resource database.Maintain up-to-date knowledge of resources and entitlements.Reporting
Assist in generating reports on IDR / Lesser of case outcomes, trends, and performance metricsAssist in building presentations to report findings to internal and external stakeholders.Perform any other relevant, or pertinent work duties as assigned by management.Qualifications :
Bachelor's degree in Healthcare Administration, Business, or a related field; or the equivalent education and / or experience3 years of experience in healthcare billing, claims, or payer-provider negotiations requiredProficiency in data entry, with attention to detail and accuracyExperience with healthcare billing and systems is a plusExcellent verbal, interpersonal, and written communication skillsAbility to communicate complex medical and regulatory information clearly and effectivelyAbility to manage multiple cases simultaneously and meet strict deadlinesExperience with the Independent Dispute Resolution process or similar healthcare arbitration processesStrong knowledge base of the healthcare industryOutstanding analytical and problem-solving skillsAbility to use Microsoft Office with emphasis on Excel and WordExcellent organizational and prioritizing skillsAbility to work on simultaneous projects with diverse working groupsExcellent customer service skills when working with claimants and hospitals to resolve disputes, answer questions and provide solutions related to medical claimsLanguage Skills :
The ability to read, write and understand English is essential
Bilingual in English / Spanish preferred
Education :
Bachelor's degree in Healthcare Administration, Business, or a related field; or the equivalent education and / or experience.
