Provider Dispute & Open Negotiation Specialist
Position Overview
The Provider Dispute & Open Negotiation Specialist is responsible for the end-to-end management of provider dispute resolution, with a strong focus on Texas open negotiation and dispute resolution (Chapter 1467) within a commercial health plan environment.
In this role, you’ll review and resolve disputed claims, manage open negotiation cases with out-of-network providers, and ensure decisions are accurate, compliant, and well-documented. You’ll also identify trends and opportunities to improve how disputes are handled across the organization and serve as a subject matter expert ensuring timely, accurate resolution of provider disputes.
Roles and ResponsibilitiesProvider Disputes
• Manage provider disputes from intake through final resolution in accordance with regulatory timeframes and internal SLAs
• Conduct detailed review of disputed claims, including review of EOBs, remittance advice, contract terms, benefit language, and coordination of benefits determinations
• Evaluate all documentation, determine whether adjustments are warranted, and process claims adjustments accurately when the dispute is overturned, in accordance with internal policies
• Draft clear, well-supported written responses to providers, including rationale for upheld decisions
Open Negotiation & Independent Dispute Resolution (IDR)
• Serve as the primary point of contact and manage all 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 required documentation
• 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 when determining which open negotiation and IDR framework applies
• Track and monitor IDR case outcomes at both the federal and state level, maintain audit-ready documentation, and 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
• Develop and present data-driven recommendations to management for process improvements, policy updates, and workflow enhancements
• 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 accurate and complete case documentation in Salesforce
• Ensure all dispute resolution activities comply 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 current 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 when to apply state regulated (fully insured) vs. ERISA (self-funded) guidelines
• Strong working knowledge of CPT, HCPCS, ICD-10, and revenue codes, as well as QPA and NSA-related regulatory requirements
• Ability to analyze complex 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 (Excel or similar tools)
Preferred Qualifications
• Associate or bachelor's degree in healthcare administration, Business, or a related field (or equivalent experience)
• Professional certification such as Certified Professional Coder (CPC), Certified Professional Biller (CPB), or similar
• Experience with FAIR Health, Cotiviti, 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 prompt 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 within 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 keep all company sensitive documents secure.
• Must live in a location that receives an existing high-speed internet connection/service
Evry Health is an EEO employer - Read More Here
The Provider Dispute & Open Negotiation Specialist is responsible for the end-to-end management of provider dispute resolution, with a strong focus on Texas open negotiation and dispute resolution (Chapter 1467) within a commercial health plan environment.
In this role, you’ll review and resolve disputed claims, manage open negotiation cases with out-of-network providers, and ensure decisions are accurate, compliant, and well-documented. You’ll also identify trends and opportunities to improve how disputes are handled across the organization and serve as a subject matter expert ensuring timely, accurate resolution of provider disputes.
Roles and ResponsibilitiesProvider Disputes
• Manage provider disputes from intake through final resolution in accordance with regulatory timeframes and internal SLAs
• Conduct detailed review of disputed claims, including review of EOBs, remittance advice, contract terms, benefit language, and coordination of benefits determinations
• Evaluate all documentation, determine whether adjustments are warranted, and process claims adjustments accurately when the dispute is overturned, in accordance with internal policies
• Draft clear, well-supported written responses to providers, including rationale for upheld decisions
Open Negotiation & Independent Dispute Resolution (IDR)
• Serve as the primary point of contact and manage all 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 required documentation
• 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 when determining which open negotiation and IDR framework applies
• Track and monitor IDR case outcomes at both the federal and state level, maintain audit-ready documentation, and 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
• Develop and present data-driven recommendations to management for process improvements, policy updates, and workflow enhancements
• 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 accurate and complete case documentation in Salesforce
• Ensure all dispute resolution activities comply 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 current 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 when to apply state regulated (fully insured) vs. ERISA (self-funded) guidelines
• Strong working knowledge of CPT, HCPCS, ICD-10, and revenue codes, as well as QPA and NSA-related regulatory requirements
• Ability to analyze complex 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 (Excel or similar tools)
Preferred Qualifications
• Associate or bachelor's degree in healthcare administration, Business, or a related field (or equivalent experience)
• Professional certification such as Certified Professional Coder (CPC), Certified Professional Biller (CPB), or similar
• Experience with FAIR Health, Cotiviti, 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 prompt 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 within 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 keep all company sensitive documents secure.
• Must live in a location that receives an existing high-speed internet connection/service
Evry Health is an EEO employer - Read More Here