Job Title: Determination Specialist

Position Type: Full-Time / Contract-to-Hire (High growth potential)

Location: Remote (IT Equipment Issued)

Industry: Healthcare / Federal Contracting (GSA)

About the Role

Are you an analytical healthcare claims specialist with direct experience handling payment disputes, provider appeals, or billing arbitrations? We are seeking an experienced Determination Specialist to join our team supporting a federal Independent Dispute Resolution Entity (IDRE) program.

Under the federal No Surprises Act, an IDRE is certified to resolve out-of-network payment disputes between healthcare providers and health plans. In this role, you will leverage your specialized background in provider dispute resolution to evaluate complex documentation, apply federal regulatory criteria, and render final, binding payment determinations for emergency services, facility care, and air ambulance cases.

This position requires demonstrated expertise in healthcare dispute resolution, claims appeals, or out-of-network payment adjudication. If you thrive in an ever-changing environment, excel at solving complex problems in the "grey," and want to apply your dispute experience to high-profile federal oversight, we want to hear from you.

Key Responsibilities

• Dispute Adjudication: Evaluate and adjudicate complex out-of-network payment disputes between healthcare providers and health plans in strict accordance with No Surprises Act guidelines.
• Binding Payment Determinations: Analyze submitted evidence, fee benchmarks, and documentation from both provider and payer to select the appropriate final payment offer.
• Regulatory Compliance: Interpret complex federal and state billing regulations to ensure every dispute determination is legally sound, impartial, and compliant.
• Case Documentation & Data Entry: Maintain precise, audit-ready case records within federal government portals.
• Performance Metrics: Manage a active portfolio of dispute cases, meeting strict turnaround deadlines and high quality-assurance standards.

Qualifications & Requirements

Essential Experience (Required):

• Direct Dispute & Appeals Background: Minimum 2+ years of experience specifically in provider payment disputes, claims appeals, out-of-network reimbursement, or health insurance dispute resolution. (Candidates without direct claims dispute or appeals experience will not be considered.)
• Analytical Expertise: Demonstrated track record of reviewing complex medical claims, Explanation of Benefits (EOBs), contract terms, and regulatory guidance to solve payment discrepancies.
• Technical Skills: Advanced data entry skills and proficiency in Microsoft Office (specifically Excel for data analysis and case tracking).
• Compliance & Screening: Must clear all background checks and meet strict federal conflict-of-interest requirements.

Preferred Knowledge:

• Education: Bachelor’s degree or equivalent combination of specialized dispute-resolution experience.
• Regulatory Knowledge: In-depth understanding of the Independent Dispute Resolution (IDR) process, the No Surprises Act, and varied plan types (Commercial, Medicare, Medicaid, Self-Funded/ERISA).

Core Competencies & Soft Skills

• Mastery in Ambiguity: Ability to make sound, independent decisions in complex cases where guidelines require nuanced interpretation.
• Precision & Detail: High level of accuracy when evaluating conflicting evidence and numerical data from opposing parties.
• High-Volume Execution: Capacity to maintain quality and speed in a fast-paced environment with a heavy backlog of cases.

What We Offer & Why You Should Join

• Massive Growth Opportunity: Backed by steady case volume and 50+ open FTE positions, offering exceptional stability and conversion to permanent roles for strong performers.
• Equipment Provided: Complete IT equipment package provided upon hire.
• High-Impact Work: Utilize your niche expertise in payment disputes on a vital federal GSA program shaping national healthcare reimbursement standards.

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients