Provider Dispute & NSA Adjuster

Provider Disputes:

• Conduct thorough research of disputed claims using EOBs, contracts, and regulatory guidelines.
• Draft clear, well-supported written responses to providers and ensure accurate processing of adjustments.

Open Negotiation & Independent Dispute Resolution (IDR):

• Manage all phases of open negotiation and IDR cases under federal and Texas-specific frameworks.
• Coordinate IDR submissions with legal and finance teams, ensuring accurate documentation and strategic soundness.
• Track and monitor IDR outcomes at both federal and state levels for audit-readiness and reporting.

Data Analysis & Process Improvement:

• Analyze dispute trends and denial patterns to identify claim adjudication errors and process gaps.
• Partner with Claims Operations to implement corrective actions and translate insights into workflow improvements.
• Support call center training by identifying knowledge gaps and developing materials on common dispute topics.