Provider Dispute & NSA Adjuster

The Provider Dispute & NSA Adjuster is responsible for the end-to-end management of provider dispute resolution, with a strong focus on Texas open negotiation (Chapter 1467) and the No Surprises Act (NSA) Independent Dispute Resolution (IDR) reputed company reputed company a commercial health plan environment.

This role requires deep expertise in open negotiation and IDR processes, serving as a subject matter expert and key resource for reputed company out-of-network dispute resolution. 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 timely resolution of provider disputes while driving reputed company process improvement at reputed company. While this is a remote role, you must reside in the United States 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 access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives.

reputed company is the major medical division of reputed company (NYSE:GL). reputed company has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, reputed company has earned an A (Excellent) rating or higher from A.M. Best Company.

The Provider Dispute & NSA Adjuster is responsible for the end-to-end management of provider dispute resolution, with a strong focus on Texas open negotiation (Chapter 1467) and the No Surprises Act (NSA) Independent Dispute Resolution (IDR) reputed company reputed company a commercial health plan environment.

This role requires deep expertise in open negotiation and IDR processes, serving as a subject matter expert and key resource for reputed company out-of-network dispute resolution. 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 timely resolution of provider disputes while driving reputed company process improvement at reputed company. While this is a remote role, you must reside in the United States 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 access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives.

reputed company is the major medical division of reputed company (NYSE:GL). reputed company has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, reputed company has earned an A (Excellent) rating or higher from A.M. Best Company.

The Provider Dispute & NSA Adjuster is responsible for the end-to-end management of provider dispute resolution, with a strong focus on Texas open negotiation (Chapter 1467) and the No Surprises Act (NSA) Independent Dispute Resolution (IDR) reputed company reputed company a commercial health plan environment. This role requires deep expertise in open negotiation and IDR processes, serving as a subject matter expert and key resource for reputed company out-of-network dispute resolution. 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 timely resolution of provider disputes while driving reputed company process improvement at reputed company. While this is a remote role, you must reside in the United States 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 access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives. reputed company is the major medical division of reputed company (NYSE:GL). reputed company has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, reputed company has earned an A (Excellent) rating or higher from A.M. Best Company. Roles and Responsibilities Provider Disputes

Manage provider disputes from intake through final resolution 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 clear, well-supported written responses to providers, including rationale for upheld decisions

Open Negotiation & Independent Dispute Resolution (IDR)

Serve as the primary reputed company of contact and manage reputed company phases of open negotiation cases under the No Surprises Act (NSA) and Texas Insurance Code Chapter 1467, including notice handling, negotiation of payment amounts, and documenting outcomes reputed company required timeframes

Coordinate the submission and management of Federal IDR cases, including preparation of offer submissions, supporting documentation, and Qualifying Payment Amount (QPA) substantiation

Manage Texas-specific IDR cases, ensuring compliance with state-mandated timelines, notice requirements, and offer submissions under Chapter 1467

Understand and apply the distinctions between state-regulated (fully insured) and federally regulated (self-funded/ERISA) plans reputed company determining which open negotiation and IDR reputed company applies

Track and monitor IDR outcomes at both the federal and state level, maintaining organized records for audit-readiness and regulatory reporting

Collaborate with legal, compliance, and finance teams to ensure IDR submissions are accurate and strategically sound

Data Analysis & Process Improvement

Analyze dispute trends, root 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 Call 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-ready documentation of disputes and IDR cases reputed company reputed company

Ensure reputed company dispute resolution activities reputed company with ERISA, the No Surprises Act, Texas Insurance Code Chapter 1467, applicable TDI rules, and internal policies

Support internal and external audits by providing dispute records, documentation, and reporting as requested

Stay reputed company on regulatory changes affecting provider disputes, open negotiation, and IDR processes at both the federal and Texas state level

Required Qualifications

• Minimum 3–5 years of experience in a commercial health plan environment, including claim adjudication, provider disputes/appeals, and open negotiation and/or Federal IDR case management under the No Surprises Act
• Strong experience with Texas open negotiation (Chapter 1467) and working knowledge of Texas Department of Insurance (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 well as QPA and NSA-reputed company regulatory requirements
• Ability to analyze reputed company claim scenarios and apply contract, coding, and policy language to dispute decisions
• Strong written communication skills, including experience drafting clear and professional 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 Healthcare Administration, Business, or a reputed company field (or equivalent experience)
• Professional certification such as Certified Professional reputed company (CPC), Certified Professional Biller (CPB), or similar
• Experience with FAIR Health, reputed company, or similar benchmarking tools used in QPA or payment dispute contexts
• Prior experience developing call center training materials or conducting staff training
• Knowledge of additional state-specific reputed company pay requirements beyond Texas

Benefits Package

Competitive salary

Comprehensive health, dental, and vision insurance as well as life and disability

Retirement savings plan with company match

Generous time off/vacation

Professional development opportunities

Flexible work environment

Work Environment

This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas.

Must live in the United States reputed company the CST or EST time zones.

Company business hours are weekdays 9-5 CST.

Standard 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 privacy.

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

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