Claims Dispute Resolution Analyst

Job Description

Job Description

Job Code
1180

Department Name
Health Fund Admin

Reports To
Manager, Health Fund Operations

FLSA Status
Exempt

Union Code
N/A

Management
No

About Us:

Building Services 32BJ Benefit Funds (“the Funds”) is the umbrella organization responsible for administering Health, Pension, Retirement Savings, Training, and Legal Services benefits to over 100,000 SEIU 32BJ members. Our mission is to make significant contributions to the lives of our members by providing high quality benefits and services. Through our commitment, we embody five core values: Flexibility, Initiative, Respect, Sustainability, and Teamwork (FIRST). By following our core values, employees are open to different and new ways of doing things, take active steps to improve the organization, create an environment of trust and respect, approach their work with the intent of a positive outcome, and work collaboratively with colleagues.

The Funds oversees and manages $9 billion of dollars in assets, which are made up of many, varied and complex funds. The dollars come from a number of sources, including the property owners who pay into the funds on behalf of their employees, and as such, requires those who oversee and manage the money to be highly skilled financial management people.

For 2025 and beyond, 32BJ Benefit Funds will continue to drive innovation, equity, and technology insights to further help the lives of our hard-working members and their families. We use cutting edge technology such as: M365, Dynamics 365 CRM, Dynamics 365 F&O, Azure, AWS, SQL, Snowflake, QlikView, and more.

Please take a moment to watch our video to learn more about our culture and contributions to our members: youtu.be/hYNdMGLn19A

Job Summary:

Under the supervision of the Manager of Health Fund Operations, the Claims Dispute Resolution Analyst will be responsible for reviewing healthcare claims flagged under the "lesser of terms" payment principle and managing cases within the Independent Dispute Resolution (IDR) process. This role involves analyzing claims, negotiating equitable reimbursement rates, and ensuring compliance with regulatory requirements, including the No Surprises Act . The Claims Dispute Resolution Analyst will collaborate with internal teams, healthcare providers, and payers to resolve disputes while maintaining accurate documentation and delivering timely results.

Essential Duties and Responsibilities:

• Case Review and Analysis
  • Conduct thorough review of disputed medical claims to determine the medical necessity of services provided to our members and identify resolution pathways
  • Analyze clinical documentation to support or contest payment disputes
  • Identify and review cases flagged under the "lesser of terms" payment principle
  • Analyze claim details, including billed charges, payer allowed amounts, and applicable contracts or benchmark rates
  • Collaborate with healthcare providers to obtain necessary clinical information and provide expert clinical insight during negotiations

• Negotiation
  • Initiate and manage rate negotiation discussions with healthcare providers and/or facilities
  • Leverage data such as industry benchmarks, comparable claims, and cost analysis to propose equitable reimbursement rates
  • Document all negotiation processes, ensuring transparency and accountability
  • Negotiate arrangements for planned care with out-of-network providers when no in-network equitable exists

• IDR Process Management
  • Coordinate the submission of notices and required documentation through various methods of receipt
  • Ensure compliance with federal regulated 30-day open negotiation period and timelines for IDR requests
  • Manage the workflow of IDR cases from initiation through final resolution

• Data Entry and Documentation
  • Accurately input case details, clinical data, and communications into internal systems
  • Maintain records of all correspondence, decisions, and outcomes related to IDR cases
  • Ensure all documentation is complete and compliant with federal regulations

• Collaboration and Communication
  • Coordinate with internal teams, including billing, compliance, and legal, to gather necessary documentation for negotiations
  • Serve as a liaison between providers and payers, facilitating efficient and amicable resolutions
  • Communicate outcomes effectively to all stakeholders, including patients when necessary

• Compliance
  • Maintain up-to-date knowledge of regulations governing claims and reimbursement, particularly around "lesser of terms" and balance billing
  • Ensure all actions and submissions are in full compliance with federal regulatory requirements
  • Support the maintenance of a resource database
  • Maintain up-to-date knowledge of resources and entitlements

• Reporting
  • Assist in generating reports on IDR/Lesser of case outcomes, trends, and performance metrics
  • Assist in building presentations to report findings to internal and external stakeholders
  • Perform any other relevant, or pertinent work duties assigned by management

Qualifications (Competencies):

• 3+ years of experience in healthcare billing, claims, or payer-provider negotiations required

• Proficiency in data entry, with attention to detail and accuracy

• Experience with healthcare billing and systems is a plus

• Excellent verbal, interpersonal, and written communication skills

• Ability to communicate complex medical and regulatory information clearly and effectively

• Ability to manage multiple cases simultaneously and meet strict deadlines

• Experience with the Independent Dispute Resolution process or similar healthcare arbitration processes

• Strong knowledge base of the healthcare industry

• Outstanding analytical and problem-solving skills

• Ability to use Microsoft Office with emphasis on Excel and Word

• Excellent organizational and prioritizing skills

• Ability to work on simultaneous projects with diverse working groups

• Excellent customer service skills when working with claimants and hospitals to resolve disputes, answer questions and provide solutions related to medical claims

Education:

Bachelor’s degree in Healthcare Administration, Business, or a related field; or the equivalent education and/or experience.

Language Skills:

The ability to read, write and understand English is essential

Bilingual in English/Spanish preferred

Reasoning Ability:

High

Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals to perform the essential functions.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals to perform the essential functions.

• Under 1/3 of the time: Standing, Walking, Climbing or Balancing, Stooping, Kneeling, Crouching, or Crawling
• Over 2/3 of the time: Talking or Hearing
• 100% of the time: Using Hands

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.