Provider Dispute and Resolution Analyst II

Job Summary

(2 positions available)

The Provider Dispute and Resolution Analyst II is responsible for researching, analyzing, coordinating, and resolving routine to moderately complex provider claims, payment disputes, and reimbursement issues for contracted network providers. This role serves as part of a dedicated provider resolution function designed to improve the timeliness and consistency of provider payment issue resolution. The Analyst II reviews provider claims, payment information, applicable contract terms, configuration, and supporting documentation to determine the appropriate resolution pathway. Working within established policies, workflows, reimbursement guidance, and escalation protocols, the Analyst II partners stakeholders to resolve provider concerns and coordinate corrective claim action when necessary.

The Analyst II provides analytical and administrative support for non-litigation provider settlement activities including claim research, payment validation, reconciliation, and tracking of approved resolution activity.  This role independently resolves routine and moderately complex matters while escalating higher-risk, systemic, financially significant, or contractually ambiguous disputes to appropriate leadership.

Duties

Safeguards the organization’s financial and reputational interests by expertly managing provider claims and reimbursement disputes. Reviews and resolves routine to moderately complex cases, requiring thorough research of claim histories and provider documentation to ensure fair and accurate outcomes. Partners with key stakeholders to validates disputes against contractual rates and payment mechanisms, documenting remediation activities with precision.

Maintains meticulous case records and fostering timely, transparent communication with providers. Escalates disputes that surpass established complexity or financial thresholds, ensuring that senior leadership is engaged when strategic oversight is required.

Delivers analytical support for provider settlement reviews by researching claims and payment histories, reconciling disputed inventories, preparing documentation for settlement evaluation, and tracking approved activities. Promptly escalates discrepancies or unresolved items, reinforcing accountability and organizational transparency.

Establishes dispute resolution policies and frameworks, preparing clear, provider-facing responses that communicate findings and resolution status The role demands objective, sensitive communication, especially in potentially challenging provider interactions.

Champion continuous improvement, share best practices, and promote a culture of accountability, collaboration, and decision quality. Builds upon foundational competencies and cultivates leadership qualities that drive organizational progress.

Ensures that the organization’s dispute resolution process is both robust and responsive by integrating analytical rigor, cross-functional collaboration, and proactive escalation Upholds contractual integrity, optimizing financial outcomes, and enhancing provider relationships.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 2 years of experience in researching, analyzing, coordinating, and resolving provider claims, payment disputes, and reimbursement issues within a healthcare or managed care environment.

Experience reviewing provider claims, payment information, contract terms, and supporting documentation to determine the appropriate resolution pathway.

Experience working within established policies, workflows, reimbursement guidance, and escalation protocols is essential, as is partnering with Claims, Configuration, Finance, and provider contract representatives to resolve provider concerns and coordinate corrective claim action when necessary.

Preferred:

Experience preparing documentation for settlement evaluation.

Skills

Required:

Demonstrate strong analytical abilities to research and resolve provider claims and reimbursement disputes.

Essential skills include meticulous record-keeping, effective cross-functional collaboration, and adherence to established dispute resolution policies.

Communications skills with the ability to have a clear, objective communication with providers, timely escalation of complex cases, and a commitment to continuous improvement and accountability.

Preferred:

Advance analytical support for settlement reviews.

Ability to escalate unresolved items to senior leadership, sharing best practices, and promoting decision quality will be highly valued.

Leadership skills that foster collaboration and drive organizational progress are also desirable.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:
Travel to offsite locations for work required.