Arbitration Case Specialist

Advantify; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

Advantify, a health technology company revolutionizing reimbursement through the No Surprises Act Independent Dispute Resolution (IDR) process, seeks an IDR Case Specialist to join our remote team. You will identify, analyze, and prepare high-value claims for arbitration, ensuring eligibility, routing disputes, and driving accurate submissions.

You will work with 837/835 files, EOBs, and payer responses, applying DRG and CPT/ASA knowledge, while maintaining regulatory compliance and delivering

Qualifications

• High School Diploma or equivalent required; Associate’s or Bachelor’s degree preferred.
• 2+ years in healthcare revenue cycle, billing, or collections across facility (DRG) and/or professional (CPT) claims.
• IDR and/or out-of-network billing strongly preferred.
• Understanding of DRG, CPT, ICD-10, HCPCS coding and charge master review.

Responsibilities

• Review 837/835 files, EOBs, and payer responses to identify NSA eligible disputes.
• Assess QPA deviations and clinical appropriateness for arbitration, benchmark offers against QPA and databases.
• Determine jurisdiction and route disputes between federal IDR and state arbitration or mediation processes.
• Compile and submit complete dispute packages via federal IDR portal and state systems.
• Ensure NSA and state IDR deadlines, including open negotiation, initiation window, batching rules, and cooling-off period.
• Monitor case status, win rates, and award projections; deliver weekly leadership updates.

Skills

Attention to detail

Analytical thinking

Time management

Regulatory knowledge

Remote collaboration

Education

High School Diploma

Associate or Bachelor's degree preferred

Tools

IDR software

Job description

We are a health technology company revolutionizing reimbursement through the No Surprises Act Independent Dispute Resolution (IDR) process. By automating and optimizing out-of-network claim disputes, we help healthcare providers recover underpaid awards. Our mission: turn complex federal and state arbitration into predictable, scalable opportunities for providers nationwide.

About This Role

The IDR Case Specialist is a critical front-line role in our IDR engine, responsible for identifying, analyzing, and preparing high-value claims for federal and state arbitration under the No Surprises Act (NSA). You will evaluate claim eligibility across both facility and professional claim types, route disputes correctly between the federal and applicable state processes, ensure compliance with regulatory portals, and drive submission accuracy to maximize recovery. This role demands precision, analytical rigor, and fluency in facility (DRG) and professional (CPT/ASA) billing and coding, and reimbursement law.

What You’ll Do

Claims Analysis & Eligibility Determination

• Review 837/835 files, EOBs, and payer responses to identify NSA eligible disputes.
• Assess qualifying payment amount (QPA) deviations and clinical appropriateness for arbitration, and benchmark offers against the QPA and applicable databases (e.g., FAIR Health).
• Correctly determine jurisdiction and route each dispute between the federal IDR process and the applicable state arbitration or mediation process.

Arbitration Preparation & Submission

• Compile and submit complete dispute packages via federal IDR portal and state insurance department systems.
• Ensure 100% compliance with NSA and state IDR deadlines, including the open negotiation period, the IDR initiation window, batching rules, and the cooling-off period.

Data Integrity & Reporting

• Manage a book of business by monitoring case status, win rates, and award projections.
• Deliver weekly updates to leadership on submission volume and recovery forecasts.
• Proactively identify and track project risks, escalating to relevant teams or leadership as needed.

Cross-Functional Collaboration

• Reprioritize tasks dynamically with manager/director based on client urgency and payer behavior.
• Support special projects and other duties as assigned.

What We Are Looking For

Education & Experience

• High School Diploma or equivalent required; Associate’s or Bachelor’s degree preferred.
• 2+ years in healthcare revenue cycle, billing, or collections across facility (DRG) and/or professional (CPT) claims.
• IDR and/or out-of-network billing strongly preferred.
• Understanding of DRG, CPT, ICD-10, HCPCS coding and charge master review, including ASA unit methodology for anesthesia.

Technical & Analytical Skills

• Ability to learn proprietary IDR software and federal/state portals quickly.

Regulatory & Industry Knowledge

• Deep understanding of HIPAA, HITECH, and privacy laws.
• Familiarity with No Surprises Act, ERISA, and state balance billing laws.
• Knowledge of insurance industry practices, payer contracting, and reimbursement methodologies.
• Awareness of current federal rulemaking (CMS IDR Operations Final Rule, CMS-9897-F) and state-specific arbitration and mediation frameworks.

Soft Skills

• Exceptional attention to detail and accuracy under tight deadlines.
• Strong organizational skills with the ability to manage a high-volume caseload and competing priorities.
• Self-directed and accountable in a fully remote environment.