PAYMENT DETERMINATIONS COORDINATOR - IDRE - REMOTE

About iMPROve Health

Come join the iMPROve Health team!

iMPROve Health is Michigan's Medicare-designated Quality Improvement Organization, and we're proud to be recognized as both a Cool Place to Work by Crain's Detroit Business (four years running) and one of Modern Healthcare's Best Places to Work in Healthcare.

As a nonprofit with more than 40 years of experience, we're dedicated to improving healthcare across the continuum of care using evidence-based, data-driven strategies. We provide medical consulting and review services, along with data analysis, to federal agencies, state Medicaid programs, public health organizations, healthcare facilities, private health plans, and other third-party payers. Our team also specializes in impartial utilization review, dispute resolution, and peer review. Our mission is simple: help healthcare get better.

This position is 100% remote, offering the flexibility to work from anywhere in the United States while collaborating with a supportive, nationwide team. We prioritize work/life balance and invest in our employees' growth through professional development and continuing education opportunities.

At iMPROve Health, we are committed to improving the quality, safety, and efficiency of healthcare. While we do not provide direct patient care, our healthcare professionals-including physicians, nurses, and experienced consultants-partner with providers to promote the use of evidence-based best practices. We offer our clients a trusted, impartial resource that understands the complexities of the healthcare landscape and is dedicated to thoughtful, high-quality solutions.

Join us in making a meaningful impact on healthcare-one improvement at a time.

Payment Determinations Coordinator | Fully Remote

About the Role

iMPROve Health is seeking a detail-oriented, organized, and experienced Payment Determinations Coordinator to support our Federal and State Independent Dispute Resolution Entity (IDRE) programs under the No Surprises Act (NSA).

In this role, you will coordinate payment determination activities, manage dispute cases and program deadlines, maintain accurate case records, and support compliance with applicable Centers for Medicare & Medicaid Services (CMS) requirements and contractual obligations. You will work closely with arbitrators, program managers, and organizational leadership to facilitate timely, accurate, and consistent case processing.

The ideal candidate has a strong understanding of the Federal No Surprises Act, excellent project and time management skills, and the ability to navigate multiple electronic systems while managing competing priorities in a fully remote environment.

Key Responsibilities

Payment Determinations and Case Management

• Coordinate dispute cases throughout the case lifecycle, from intake through final resolution.
• Review case submissions for completeness, accuracy, eligibility, and compliance with applicable program requirements.
• Coordinate case assignments to arbitrators, reviewers, and other appropriate decision-makers.
• Complete payment determination processing following arbitrator review in accordance with established procedures and program requirements.
• Monitor case status, deadlines, and outstanding activities to ensure timely resolution.
• Maintain accurate case information, documentation, and communications in CMS portals and internal databases.
• Respond to arbitrator inquiries and provide procedural guidance regarding case requirements and workflows.

Program Operations and Compliance

• Complete assigned contract deliverables and operational activities within established timelines.
• Monitor work plans, schedules, and case-processing activities to identify potential delays, risks, or operational issues.
• Ensure compliance with applicable CMS requirements, HIPAA, FISMA, URAC standards, contractual obligations, and internal policies.
• Conduct quality reviews to promote accuracy, consistency, and adherence to established procedures.
• Identify discrepancies, compliance concerns, and opportunities for process improvement, escalating issues as appropriate.
• Assist with the implementation and enhancement of operational systems, tools, and workflows.

Training and Documentation

• Develop, update, and maintain standard operating procedures (SOPs), job aids, templates, FAQs, troubleshooting guides, and other operational resources.
• Develop and deliver onboarding and ongoing training related to IDRE workflows, CMS portal navigation, documentation standards, and communication protocols.
• Collaborate with program managers and leadership to ensure training materials reflect current regulatory guidance, contractual requirements, and internal policies.
• Conduct refresher training and assist in identifying knowledge gaps and additional training needs.
• Communicate process changes and updates to affected team members.

Communication and Collaboration

• Coordinate with internal teams and external stakeholders, including arbitrators, providers, payers, legal representatives, and other dispute resolution participants.
• Serve as a point of contact for procedural questions, submission requirements, and case status inquiries.
• Maintain neutral, professional, and clear communication throughout the dispute resolution process.
• Collaborate with operations, compliance, legal, finance, IT, and other teams to resolve issues and support program objectives.
• Participate in meetings concerning operational priorities, escalations, stakeholder feedback, and policy updates.

Reporting and Continuous Improvement

• Prepare operational reports related to case volume, resolution outcomes, turnaround times, outreach activities, and performance metrics.
• Maintain spreadsheets, tracking tools, and dashboards to monitor service levels, response times, case aging, and operational trends.
• Analyze operational data and stakeholder feedback to identify opportunities to improve efficiency, accuracy, and service delivery.
• Support special projects and other duties as assigned.

Required Qualifications

• Bachelor's degree in a healthcare-related field or equivalent relevant experience.
• At least five years of project support experience in a corporate or professional environment, with a demonstrated ability to meet deadlines.
• Knowledge of the Federal No Surprises Act.
• Strong organizational, project management, and time management skills.
• Excellent written and verbal communication skills.
• Strong attention to detail, reliability, accountability, and problem-solving skills.
• Ability to manage multiple priorities, work independently, and meet deadlines in a fast-paced environment.
• Ability to handle confidential and sensitive information appropriately.
• Proficiency with Microsoft Office applications, Windows-based software, and web-based portals.
• Experience developing and maintaining moderately complex spreadsheets.
• Ability to navigate multiple electronic systems and cloud-based platforms while maintaining accurate records and data integrity.
• Ability to collaborate effectively with internal teams and external stakeholders.

Preferred Qualifications

• Master's degree in a healthcare-related or relevant field.
• Familiarity with healthcare billing, reimbursement, and payer-provider processes.
• Experience reviewing medical claims, remittance advice, and Explanation of Benefits (EOBs).
• Understanding of quality improvement concepts.
• Experience developing training materials, SOPs, and operational documentation.
• Experience supporting portal development, system enhancements, or workflow improvement initiatives.
• Familiarity with CMS portals, Salesforce, and other third-party platforms.

Remote Work Requirements

This is a fully remote position. Candidates must be able to:

• Maintain a reliable high-speed internet connection suitable for business applications and virtual communications.
• Maintain a private, secure, professional, and distraction-free workspace.
• Protect confidential information, including protected health information (PHI), in accordance with HIPAA, FISMA, URAC, CMS, and organizational requirements.
• Work independently, manage competing priorities, and consistently meet established deadlines.
• Maintain regular availability and communication during scheduled work hours.
• Effectively collaborate through virtual meetings, approved communication tools, and electronic systems.

Why Join iMPROve Health?

Join a team dedicated to healthcare quality, regulatory compliance, and effective dispute resolution. In this role, you will contribute to important healthcare operations while collaborating with colleagues and stakeholders across a fully remote organization.

EEO/VET/Disability Employer