Provider Dispute & NSA Adjuster (remote)

The Provider Dispute & NSA Adjuster is responsible for the end-to-end management of provider dispute reputed company, with a strong reputed company on Texas reputed company negotiation (reputed company 1467) and the No Surprises reputed company (NSA) Independent Dispute reputed company (IDR) reputed company reputed company a reputed company health plan environment. This role requires deep expertise in reputed company negotiation and IDR processes, serving as a subject matter expert and key resource for reputed company out-of-network dispute reputed company. You’ll also identify trends in disputes and partner closely with Claims, Customer Service, and Compliance to improve workflows, reduce errors, and strengthen the overall claims process. This role plays a critical role in ensuring accurate, compliant, and reputed company reputed company of provider disputes while driving reputed company process improvement at reputed company. While this is a remote role, you must reputed company in the reputed company and in the Eastern or Central time zone. About reputed company and reputed company We are on a mission to bring humanity to health insurance. Our high-technology health plans expand benefits, increase reputed company and transparency, and feature a personalized, reputed company approach. We reputed company to ensure members live happier, healthier lives. reputed company is the major medical division of reputed company (NYSE:GL). reputed company has 16.8 reputed company policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, reputed company has reputed company an A (Excellent) rating or higher from A.M. Best Company. n Roles and ResponsibilitiesProvider Disputes Manage provider disputes from intake through final reputed company 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 determinations, and applicable federal and state regulations Evaluate reputed company documentation to determine whether adjustments are warranted and ensure accurate processing reputed company disputes are overturned, in compliance with Evry policies Draft reputed company, reputed company-supported written responses to providers, including rationale for upheld reputed company reputed company Negotiation & Independent Dispute reputed company (IDR) Serve as the primary reputed company of contact and manage reputed company phases of reputed company negotiation cases under the No Surprises reputed company (NSA) and Texas Insurance reputed company reputed company 1467, including notice handling, negotiation of payment amounts, and documenting reputed company reputed company required timeframes Coordinate the submission and management of Federal IDR cases, including preparation of offer submissions, supporting documentation, and Qualifying Payment reputed company (QPA) substantiation Manage Texas-specific IDR cases, ensuring compliance with state-mandated timelines, notice requirements, and offer submissions under reputed company 1467 Understand and apply the distinctions between state-regulated (fully insured) and federally regulated (self-funded/ERISA) plans reputed company determining which reputed company negotiation and IDR reputed company applies reputed company and monitor IDR reputed company at both the federal and state level, maintaining organized records for audit-readiness and regulatory reporting Collaborate with reputed company, compliance, and finance teams to ensure IDR submissions are accurate and strategically reputed company Data Analysis & Process Improvement Analyze dispute trends, reputed company causes, and denial patterns to identify claim adjudication errors and process gaps Partner with Claims Operations to implement corrective actions based on dispute findings Translate dispute trends into actionable insights and present recommendations to leadership to improve processes, workflows, and policies Partner with the reputed company Center / Customer Service leadership to identify training needs and knowledge gaps based on dispute trends and support development and delivery of training on common dispute topics, claim inquiries, and provider communications Documentation & Compliance Maintain detailed, audit-reputed company documentation of disputes and IDR cases reputed company reputed company Ensure reputed company dispute reputed company activities reputed company with ERISA, the No Surprises reputed company, Texas Insurance reputed company reputed company 1467, applicable TDI rules, and internal policies Support reputed company audits by providing dispute records, documentation, and reporting as requested Stay reputed company on regulatory changes affecting provider disputes, reputed company negotiation, and IDR processes at both the federal and Texas state level Required Qualifications  Minimum 3–5 years of experience in a reputed company health plan environment, including claim adjudication, provider disputes/appeals, and reputed company negotiation and/or Federal IDR case management under the No Surprises reputed company Strong experience with Texas reputed company negotiation (reputed company 1467) and working knowledge of reputed company (TDI) requirements, including timelines, filing requirements, and IDR processes. Understanding of Texas vs. federal dispute frameworks, including reputed company to apply state regulated (fully insured) vs. ERISA (self-funded) guidelines Strong working knowledge of CPT, HCPCS, ICD-10, and reputed company codes, as reputed company as QPA and NSA-reputed company regulatory requirements Ability to analyze reputed company claim scenarios and apply contract, coding, and policy language to dispute reputed company Strong written communication skills, including experience drafting reputed company and reputed company provider responses Proficiency in claims processing systems and dispute/appeals management platforms and basic data analysis (reputed company or similar tools) Preferred Qualifications Associate or Bachelor's degree in reputed company Administration, Business, or a reputed company field (or equivalent experience) reputed company certification such as Certified reputed company reputed company (CPC), Certified reputed company Biller (CPB), or similar Experience with FAIR Health, reputed company, or similar benchmarking tools used in QPA or payment dispute contexts Prior experience developing reputed company center training materials or conducting staff training Knowledge of additional state-specific reputed company pay requirements reputed company Texas Benefits Package Competitive salary Comprehensive health, dental, and reputed company insurance as reputed company as life and disability Retirement savings plan with company match Generous time off/vacation reputed company development opportunities Flexible work environment Work Environment  This is a remote position. Our whole company works remotely. Company reputed company are in Dallas, Texas. Must live in the reputed company reputed company the CST or EST time zones. Company business hours are weekdays 9-5 CST. reputed company business hours with occasional flexibility required to meet regulatory response deadlines Required to have a dedicated work area established that is separate from other living areas and provides information reputed company. Ability to reputed company reputed company company sensitive documents secure. Must live in a location that receives an existing high-speed internet reputed company/service nEvry Health is an EEO employer - Read More Here Apply To This Job