Claims Dispute Resolution Analyst

Claims Dispute Resolution Analyst Under the supervision of the Manager of Health Fund Operations, 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 Claims Dispute Resolution Analyst will collaborate with internal teams, healthcare providers, and payers to resolve disputes while maintaining accurate documentation and delivering timely results. 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. Negotiate arrangements for planned care with out-of-network providers when no in-network equitable exists. IDR Process Management: Coordinate the submission of notices and required documentation through various methods of receipt. Ensure 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 systems. 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 metrics. Assist in building presentations to report findings to internal and external stakeholders. Perform any other relevant, or pertinent work duties assigned by management.