Senior Dispute Determination Specialist

Job description

Position summary:
Senior-level contributor who processes the full range of IDRE dispute reviews, including High Dollar Payment Determination Reviews and Default Determination Reviews involving material financial or stakeholder impact. Cross-trained across Eligibility and Payment Determination review types and available to support either queue as volume requires. Operates with greater autonomy than the HIS role and is expected to apply sound, defensible, and consistent judgment on complex disputes in compliance with CMS and URAC requirements.

Essential functions:
*Process standard Eligibility Reviews and Payment Determination Reviews as queue volume requires
*Process High Dollar Payment Determination Reviews, applying elevated critical-thinking and judgment to disputes with material financial or stakeholder impact
*Process Default Determination Reviews, applying working knowledge of accounting and payment reconciliation concepts
*Exercise independent judgment on complex or ambiguous disputes, escalating only true edge cases to Team Lead
*Maintain case records and documented decision rationale to CMS and URAC audit standards
*Provide cross-functional surge coverage across Eligibility, Payment Determination, and Dispute review queues as volume fluctuates
*Flag recurring case patterns, documentation gaps, or process risks to Team Lead / QA
*Meet accuracy and throughput targets appropriate to complex case review
*Audit ready at all times

Minimum qualifications:
*1+ years as a Health Insurance Specialist at PRI, or equivalent eligibility/payment determination experience, with a demonstrated record of accuracy on production and audit metrics
*Proven cross-training and performance across both Eligibility and Payment Determination review types
*Strong critical-thinking and independent judgment skills, evidenced by a track record on complex or escalated cases
*Working knowledge of, or demonstrated willingness to train into, accounting and payment reconciliation concepts supporting Default Determination Reviews
*No legal degree or bar admission required
*Proficiency in PRI's case management system
*No Surprises Act or IDRE experience strongly preferred

This job description is not an employment contract and is subject to change. PRI is an equal opportunity employer.