Provider Dispute Analyst

Location:

Avera Health Plans

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$58,240.00 - $87,360.00

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The Provider Dispute Analyst is responsible for overseeing and continuously enhancing the processes related to provider disputes management, qualified payment amount (QPA) determinations, open negotiation process (ONP), and independent dispute resolution (IDR), and provider dispute management. This role ensures that payment processes and dispute resolutions are conducted in compliance with regulatory requirements and internal policies while maintaining fairness, transparency, and operational efficiency. This position will collaborate with internal stakeholders and external providers to drive best practices and timely resolutions.

What you will do

• Oversee provider dispute, QPA, ONP, IDR process, ensure payment determinations are accurate, consistent, and compliant with regulatory and contractual requirements.
• Develop, document, and refine workflows and procedures to maintain and improve provider dispute, QPA, ONP and IDR process and ensuring unbiased and timely resolution of disputes in line with applicable guidelines. Maintain current knowledge of relevant laws, regulations and industry standards.
• Conduct investigations by gathering evidence and coordinating with legal counsel, regulatory bodies and external vendors to ensure the process meets all standards.
• Responsible for intake, processing, coordinating all materials and information relating to open negotiations and independent disputes as regulated by federal or state agencies.
• Ensure timely responses to Independent Dispute Resolution (IDR) filings according to statute.
• Serve as the primary point of contact for provider dispute resolution, ensuring inquiries and disputes are handled promptly and effectively.
• Document and track provider disputes, opening and managing negotiation processes when necessary while protecting confidentiality and security of sensitive information.
• Develop and prepare comprehensive reports including key performance indicators (KPIs) to measure the efficiency and effectiveness of the QPA, IDR, and provider dispute processes and communicate KPI performance on a weekly basis to relevant stakeholders.
• Manage the APA-IDR email box to analyze and assess incoming disputes and negotiation requests, ensuring inquiries are responded to within established timelines, and collaborate with cross functional teams and provide training and guidance to staff on dispute resolution practices.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Bachelor's in Healthcare Administration, Business, Finance, Paralegal, or a related field.
• In-depth knowledge of qualified payment amount processes, independent resolution protocols, and provider dispute procedures.
• Strong analytical skills with proficiency in data analysis and reporting.
• Exceptional communication, negotiation, and interpersonal skills.
• Detail oriented with the ability to manage multiple projects and drive process improvement.
• Proven track record of implementing process enhancements in a fast-paced environment.
• Familiarity with regulatory requirements and industry standards in healthcare payments and dispute resolution.

Preferred Education, License/Certification, or Work Experience:

• 4-6 years In healthcare payment processing, provider relations, or dispute resolution within a health insurance or managed care environment.

Expectations and Standards