Dispute Resolution Specialist

About the Role

IPRO is seeking a Dispute Resolution Specialist to independently administer and adjudicate healthcare payment disputes under the federal No Surprises Act Independent Dispute Resolution (IDR) process. This role involves reviewing and evaluating disputes between healthcare providers, facilities, and health plans to determine appropriate reimbursement amounts in accordance with applicable federal laws, regulations, guidance, and IDR requirements.

Responsibilities

• Adjudicate Independent Dispute Resolution (IDR) Cases: Independently manage healthcare payment disputes from case assignment through final determination using the CMS Federal IDR Portal and other designated systems.
• Review Party Submissions and Evidence: 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.
• Analyze Reimbursement Factors: 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.
• Evaluate Clinical and Billing Documentation: Review medical records, itemized bills, clinical documentation, and related materials to determine the appropriateness of billed services and support evidence-based payment determinations.
• Interpret Regulatory and Contractual Information: Research and analyze applicable federal statutes, regulations, guidance, payer information, fee schedules, and relevant contractual data to support dispute resolution decisions.
• Issue Written Determinations: Prepare clear, objective, and well-supported written determinations that explain the rationale for payment selections and comply with federal IDR requirements. Document the status of dispute resolutions accurately.
• Maintain Compliance and Neutrality: 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.

Qualifications

• Familiarity with healthcare claims and appeals processes.
• Excellent communication skills.
• Ability to interact with healthcare providers and commercial payors or managed care organizations.
• Must work well independently or as part of a team.
• Comfortable in a fast-paced environment with strong attention to detail.

Preferred Qualifications

• Knowledge of healthcare quality measures, performance improvement methodologies, and health equity frameworks.
• Familiarity with electronic health record and healthcare claims data.
• Advanced analytical and problem-solving skills.
• Strong understanding of research design, measurement, and evaluation methodologies.
• Ability to create meaningful data visualizations and executive-level reports.
• Ability to work independently while collaborating effectively within multidisciplinary teams.
• Ability to translate data into actionable recommendations that support decision-making and program improvement.

Education and Experience

• Associate's degree with 4 years of experience in medical billing, auditing, or claims review, appeals, or dispute resolution in healthcare or insurance industries.
• OR Bachelor's degree with 3 years of experience in medical billing, auditing, or claims review, appeals, or dispute resolution in healthcare or insurance industries.

Pay

The annualized salary range for this position is $75,000.00 - $80,000.00. Actual salary depends on factors including experience, education, credentials, location, and budget.