Senior Provider Claims Dispute Specialist

Zing Health•Remote, IL

7d•$35 - $39

About The Position

The Senior Provider Claims Dispute Specialist is responsible for the timely, accurate, and compliant resolution of complex provider disputes related to claims adjudication, reimbursement, coding, authorization decisions, and benefit application. This role serves as a subject matter expert for provider dispute resolution policies, CMS requirements, reimbursement methodologies, and provider contract interpretation. The position independently investigates escalated and regulatory-sensitive disputes, processes necessary claim adjustments and overpayment recoveries, conducts root cause and financial impact analyses, develops dispute reporting, and partners across the organization to improve claims accuracy, provider experience, operational performance, and compliance outcomes.

Requirements

Associate's degree in Healthcare Administration, Business Administration, Finance, Nursing, or a related field required; bachelor's degree preferred.
Equivalent relevant experience will be accepted in lieu of the required degree or diploma.
Five to seven years of progressive experience in Medicare Advantage claims operations, provider dispute resolution, appeals, payment integrity, or healthcare reimbursement.
Three or more years of experience handling complex provider disputes or claims appeals.
Experience interpreting provider contracts and reimbursement methodologies.
Advanced knowledge of managed care claims operations, provider dispute resolution, Medicare Advantage, Medicaid, and applicable regulatory requirements.
Knowledge of healthcare reimbursement methodologies, medical terminology, coding systems and groupers, including ICD-10, CPT, HCPCS, DRG, and ASC, and claim forms including UB-04 and CMS-1500.
Ability to interpret provider contracts, reimbursement terms, benefits, authorizations, coding, and regulatory requirements and apply them to complex payment determinations.
Strong analytical, critical-thinking, research, and problem-solving skills, including the ability to identify discrepancies, determine root causes, quantify financial impact, and recognize provider or payment patterns.
Ability to develop and maintain reports and dashboards and communicate findings clearly to operational partners and leadership.
Excellent written and verbal communication, consultation, and relationship-building skills.
Strong organizational, time-management, and attention-to-detail skills with the ability to manage competing priorities and sensitive deadlines.
Intermediate proficiency in Microsoft Office applications, including Word and Excel.

Nice To Haves

bachelor's degree preferred

Responsibilities

Serve as a subject matter expert for provider dispute resolution policies, CMS requirements, and reimbursement methodologies.
Provide guidance and consultation to Claims Operations, Provider Services, Configuration, and Compliance teams regarding dispute resolution issues.
Interpret provider contracts, reimbursement methodologies, and regulatory requirements to support complex dispute determinations.
Independently investigate and resolve escalated, high-dollar, highly complex, and regulatory-sensitive provider disputes.
Perform comprehensive payment reviews involving contract interpretation, authorization determinations, coding analysis, and benefit application.
Respond to complex provider inquiries regarding claims adjudication and payment determinations.
Ensure disputes are resolved accurately and within applicable regulatory and organizational timeframes.
Maintain complete and accurate records of dispute research, determinations, correspondence, claim adjustments, recoveries, and related tracking activities.
Develop and maintain dispute trending reports and dashboards.
Analyze dispute volume, root causes, financial impact, provider patterns, payment trends, and recurring operational issues.
Identify payment errors, process gaps, training needs, and system configuration issues; escalate findings and support corrective action.
Contribute findings and recommendations to leadership and present information when requested to help reduce dispute volume and improve operational performance.
Maintain advanced knowledge of CMS, Medicare Advantage, Medicaid, and applicable state regulations affecting claims payment disputes.
Conduct regulatory reviews and support implementation of regulatory changes impacting provider dispute processes.
Apply applicable compliance requirements, including HIPAA, CMS, and state-specific requirements, when reviewing and resolving disputes.
Participate in cross-functional initiatives designed to improve claims accuracy, provider experience, operational efficiency, and compliance outcomes.
Collaborate with Configuration, Provider Network, Provider Services, Quality, Compliance, Claims Operations, and IT teams to implement corrective actions.
Provide dispute-related expertise to support operational projects and process improvements.
Participate in dispute-related audit activities and serve as a subject matter resource, in partnership with other responsible stakeholders, during internal, external, CMS, and state regulatory audits.
Identify and quantify financial impacts resulting from payment inaccuracies and dispute trends.
Assist with audit requests, documentation, research, and follow-up activities related to provider disputes.