Dispute Resolution Specialist

Job Description

IPRO is seeking a Dispute resolution specialist to independently administer and adjudicates 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. You will provide all parties with the opportunity to submit supporting documentation and evidence for consideration and will conduct impartial, evidence-based reviews and render binding determinations. The Dispute Resolution Specialist will perform highly complex analytical and adjudicative work under general supervision, exercising substantial independent judgment, discretion, and decision-making authority.

This role is suitable for someone with acute critical thinking and analytical skills. Duties to include but not limited to:

• Adjudicate Independent Dispute Resolution (IDR) Cases. Independently manage healthcare payment disputes arising under the No Surprises Act 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 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.

Required Qualifications

• Familiarity with healthcare claims and appeals processes.
• Excellent communication skills.
• Must be able to interact with healthcare providers and commerical payors, or managed care organizations.
• Must work well independently or as a part of a team.
• Must be comfortable in a fast paced environment and have 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

• Associates 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 industry.

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. The annualized salary range for this position is $75,000.00 - $80,000.00. Actual salary range and /or hourly rate depends on a variety of factors including experience, education, credentials, location, and budget.

The salary range and/or hourly rate listed does not include other forms of compensation or benefits.

IPRO is an Equal Opportunity Employer. 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.