Provider Dispute & Adjustment Specialist

Key Responsibilities

Provider Dispute Intake & Management
• Manage provider disputes from initial intake through final resolution, ensuring adherence to regulatory timeframes, state prompt-pay requirements, and internal SLAs.
• Review and validate all incoming dispute submissions to confirm completeness; identify and communicate deficiencies to providers in a timely and professional manner.
• Accurately log, track, and maintain dispute inventories within Salesforce or applicable case management systems, ensuring real-time case status visibility.
• Prioritize and manage a high-volume caseload while maintaining accuracy, thoroughness, and compliance with established turnaround standards.
• Identify when cases require escalation to senior staff, management, legal, or other internal departments and facilitate appropriate handoffs.
Research, Investigation & Analysis 
• Conduct thorough, independent research into disputed claims by reviewing EOBs, remittance advice, claim histories, coordination of benefits (COB) determinations, eligibility records, provider contracts, fee schedules, and applicable benefit language.
• Investigate root causes of payment discrepancies, including contract misapplication, coding errors, system configuration issues, benefit plan misinterpretation, and eligibility discrepancies.
• Evaluate new information and documentation submitted by providers against the original claim decision.
• Review all relevant information — including the original determination rationale, supporting documentation, and any new evidence — to independently assess whether a reversal or modification of the original decision is warranted.
• Apply knowledge of CPT, HCPCS, ICD-10, revenue codes, and billing guidelines to evaluate the validity of disputed charges and determine appropriate payment outcomes.
• Analyze and interpret complex provider requests, identify the specific issue(s) raised, and determine the most appropriate and complete course of action for resolution.
• Review applicable state and federal regulations, internal policies, and provider contract terms to support well-reasoned dispute determinations.
• Gather, organize, and evaluate all pertinent documentation — including claim history, supporting provider correspondence, and system notes — to build a complete case record prior to issuing a determination.
Claim Adjustments & Payment Corrections
• Initiate and process claim adjustments for disputes determined to be valid, ensuring corrections are applied accurately and completely in claims processing systems.
• Remediate impacted claims identified through the dispute process, including bulk adjustments when systemic errors are identified.
• Verify that adjusted claims are reprocessed in accordance with the correct contract, benefit, and coding guidelines, and that resulting payments are accurately issued.
• Validate adjustment outcomes post-processing and communicate finalized results to providers in a clear and timely manner.
• Document all adjustment actions, rationale, and outcomes in the case management system for audit-readiness and regulatory reporting.
Provider Communications & Written Correspondence 
• Draft clear, professional, and well-supported written responses to providers for all dispute determinations — both upheld and overturned — ensuring that all points raised by the provider are directly and thoroughly addressed.
• Compose acknowledgment letters, resolution letters, and reconsideration notices in accordance with regulatory requirements and internal communication standards.
• Ensure all written correspondence is accurate, concise, free of jargon, and appropriate for the intended audience, whether a billing department, practice manager, or hospital administrator.
• Maintain consistent, professional communication throughout the dispute lifecycle, including follow-up correspondence when additional information is requested.
• Serve as a knowledgeable resource for providers navigating the dispute and adjustment process, responding to inquiries in a timely and informative manner.
Trend Analysis & Process Improvement 
• Analyze dispute and adjustment trends to identify patterns in claim adjudication errors, billing code misapplication, contract misinterpretation, or system configuration issues.
• Partner with the VP of Operations to develop and implement corrective action plans based on findings from dispute and adjustment activity.
• Translate dispute data and root cause analysis into actionable insights and present recommendations to leadership to improve workflows, reduce error rates, and strengthen the overall claims process.
• Collaborate with Customer Service leadership to identify training gaps and support the development of educational materials related to billing, coding, claim submission, and dispute processes for the CSRs.
• Contribute to the development and maintenance of department policies, procedures, and job aids.
Documentation & Regulatory Compliance 
• Maintain detailed, audit-ready case documentation for all disputes, adjustments, within Salesforce or the designated case management platform.
• Ensure all dispute activity complies with applicable state and federal regulations, including ERISA requirements, state prompt-pay statutes, Texas Department of Insurance (TDI) rules, and internal policies.
• Support internal and external audits by providing complete and organized dispute records, resolution documentation, and reporting as requested.
• Stay current on regulatory changes affecting provider dispute resolution, claims payment requirement processes at both the federal and state level.
• Adhere to all privacy, confidentiality, and data security requirements in the handling of provider and member information.

Required Qualifications

• Minimum 3–5 years of experience in a commercial health plan, managed care organization, or third-party administrator (TPA) environment, with direct responsibility for provider dispute resolution, claim adjustments, and/or provider appeals.
• Demonstrated experience reviewing and resolving provider payment disputes, billing reconsiderations, and claim adjustment requests from intake through final written determination.
• Strong working knowledge of claim adjudication principles, including CPT, HCPCS, ICD-10, revenue codes, modifiers, and fee schedule application.
• Solid understanding of provider contract terms, benefit plan language, and reimbursement methodologies, with the ability to apply this knowledge to dispute resolution decisions.
• Exceptional written communication skills, including demonstrated ability to draft clear, professional, and thorough provider-facing correspondence and determination letters.
• Strong research and investigative skills, including the ability to independently gather, analyze, and synthesize information from multiple sources to reach well-supported conclusions.
• Ability to interpret complex and sometimes ambiguous provider requests, identify the underlying issue(s), and formulate a complete and appropriate response.
• Strong analytical and critical-thinking skills with the ability to evaluate claim scenarios, apply policy and contract language, and make sound, independent determinations.
• Highly organized, detail-oriented, and capable of managing a high-volume caseload with competing deadlines while maintaining accuracy and compliance.
• Proficiency in claims processing systems, case management platforms (e.g., Salesforce), and Microsoft Office Suite (particularly Excel and Word).
• Working knowledge of applicable state and federal regulations governing provider disputes and claims, including ERISA, state prompt-pay laws, and TDI requirements.

Preferred Qualifications

• Associate or Bachelor’s degree in Healthcare Administration, Business, Health Information Management, or a related field (or equivalent professional experience).
• Professional certification such as Certified Professional Biller (CPB), Certified Professional Coder (CPC), Certified Claims Adjuster, or similar credential.
• Experience with multiple lines of business, including commercial fully insured, self-funded ERISA plans, and/or individual/group market products.
• Knowledge of Texas-specific prompt-pay statutes and TDI regulatory requirements.
• Prior experience developing or delivering training materials related to provider billing, dispute processes, or claims adjudication.
• Experience with Coordination of Benefits (COB), subrogation, and eligibility-related dispute scenarios.
• Familiarity with benchmarking and repricing tools used in payment analysis contexts.

Core Competencies

Analytical Thinking

Breaks down complex claim scenarios to identify root cause and appropriate resolution.

Research & Investigation

Independently sources, evaluates, and synthesizes information to support sound decisions.

Written Communication

Produces clear, professional, and well-reasoned written determinations and correspondence.

Regulatory Knowledge

Applies current knowledge of state and federal rules governing provider claims and disputes.

Attention to Detail

Consistently produces accurate work product with minimal errors under deadline pressure.

Adaptability

Navigates changing regulatory environments and shifting priorities with professionalism.

Cross-Functional Collaboration

Partners effectively with Claims, Compliance, Legal, and Provider Relations teams.

Work Environment

• This is a fully remote position. Candidates must reside in the United States within the Central (CST) or Eastern (EST) time zone.
• Standard business hours are Monday through Friday, 9:00 AM – 5:00 PM CST, with occasional flexibility required to meet regulatory response deadlines.
• Must maintain a dedicated, private workspace that is separate from other living areas and supports the secure handling of confidential information.
• Must have a reliable high-speed internet connection.
• All company-sensitive documents must be kept secure and handled in accordance with Evry Health data privacy and security policies.