Senior Dispute Resolution Specialist

Job description

Position Summary:
Under the direction of the Independent Dispute Resolution Entity (IDRE) Department, the Senior Dispute Resolution Specialist serves as the "face" of PRI's IDRE Program. This role applies deep knowledge and experience in dispute eligibility, arbitration, research, regulatory guidance, and policy application to research and respond to stakeholder requests, inquiries, and complaints. The Senior Dispute Resolution Specialist serves as a trusted party representing PRI's interests as well as the interests of stakeholders - providers, plans, payers, and government entities - in communicating IDRE decisions in accordance with applicable state or federal law.

The role must be well versed in IDRE regulations and skilled at communicating with members of the health community from an educational perspective, clearly explaining how applicable law relates to specific disputes across the program and with stakeholders.

The Senior Dispute Resolution Specialist reviews case documentation, renders independent determinations, and completes required notifications. The role also manages stakeholder communications - information requests, withdrawals, and inquiries - and contributes to continuous quality improvement.

Essential Functions:
* Manage stakeholder communications, including requests for information, withdrawals, and inquiries
* Research and resolve escalated concerns from stakeholders, applying elevated critical-thinking and judgment to disputes with material financial or stakeholder impact
* Root-cause stakeholder complaints and present areas of opportunity for improvement to Leadership
* Engage with clients and partners professionally (phone and/or email), representing PRI's mission, vision, and values
* Collaborate with internal teams to ensure high-quality, timely deliverables that meet contractual obligations
* Apply working knowledge of accounting and payment reconciliation concepts
* Exercise independent judgment on complex or ambiguous disputes, escalating only true edge cases to Leadership
* Maintain case records and documented decision rationale to CMS and URAC audit standards
* Provide cross-functional surge coverage across Eligibility, Payment Determination, High Dollar Payment Determination, and Default Determination Review queues as volume fluctuates
* Flag recurring case patterns, documentation gaps, or process risks to Supervisor / QA
* Meet accuracy and throughput targets appropriate to complex case review
* Audit ready at all times

Minimum Qualifications
* 2+ years as Sr Determination Specialist (Sr HIS) at PRI, or 3+ years of equivalent eligibility/payment determination experience at a comparable complexity level, with a demonstrated record of accuracy on production and audit metrics
* Paralegal certificate or law degree preferred; no legal degree or bar admission required
* Proven cross-training and performance across Eligibility, Payment Determination, and Default 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
* Proficiency in PRI's case management system
* No Surprises Act or IDRE experience strongly preferred