About iMPROve Health

Come join the iMPROve Health team! iMPROve Health is Michigan’s Medicare-designated Quality Improvement Organization. We are both a Cool Place to Work (Crain’s Detroit Business) for the last 4 years and one of the Best Places to Work in Healthcare as judged by Modern Healthcare. As a nonprofit organization, we have more than 35 years’ experience improving healthcare across the continuum of care using evidence-based and data-driven logic. iMPROve Health provides medical consulting and review, as well as data analysis to federal agencies, state Medicaid and public health organizations, healthcare facilities, private health plans and other third-party payers. We also have extensive experience completing thoughtful and impartial utilization review, dispute resolution and peer reviews. Our goal is simple – to help healthcare get better!

This position is 100% remote and provides the opportunity to work virtually with team members from anywhere within the United States. We pride ourselves on providing a great work/life balance for employees, while also providing the ability to promote their career development and gain new skills through employee education opportunities. iMPROve Health offers a wonderful benefit package that includes medical, dental, vision, life insurance, short term and long-term disability, and a generous 401k match.

iMPROve Health is committed to improving the quality, safety, and efficiency of healthcare. Although we do not see patients, we are healthcare professionals (including physicians and nurses) and consultants who work with healthcare providers to promote the adoption and use of evidence-based best practices and processes to achieve our healthcare quality goals. Our services offer our clients and partners access to a proven, impartial, connected resource that understands the intricacies of healthcare. It is our #1 priority to provide thoughtful evidence-based strategies and solutions that help them achieve their healthcare quality improvement goals and outcomes.

*Must be able to work M-F normal business hours in EST.

**All work must be performed within the United States.

SUMMARY:

The Healthcare Arbitrator will collaborate with the Federal Independent Dispute Resolution Entity (IDRE) team to deliver impartial decisions in accordance with the No Surprises Act (NSA), federal guidance for certified entities, and specified quality standards. The Arbitrator will be responsible for applying baseball-style arbitration to issue fair, impartial, and timely written resolutions for a large volume of disputes.

DUTIES AND RESPONSIBILITIES:

• Make fair and unbiased final payment determinations: Implement iMPROve Health guidelines, the NSA, and guidance published by the Departments of the Treasury, Labor, and Health and Human Services (collectively, the Departments) to make impartial, concise, and well-informed final payment decisions.
• Conduct case reviews and final payment determinations: Apply in-depth knowledge of the NSA and its implementing regulations to thoroughly review and analyze cases and determine final payments using baseball-style arbitration, ensuring compliance with all relevant regulations and standards.
• Identify opportunities for process improvement: Collaborate with the Arbitration Program Manager and IDRE team to continuously identify and implement opportunities for process improvement, with a focus on increasing the volume of high-quality payment determinations.
• Stay updated on regulatory requirements: Maintain up-to-date knowledge of all regulations, and proposed rule changes impacting decision-making for certified Federal IDREs, ensuring that all payment determinations are made in compliance with the latest guidelines and regulatory changes.
• Ensure compliance with the NSA requirements: Adhere to the standards for certifying IDREs as outlined in 45 CFR Part 149 and the parallel provisions governing the Federal IDR Process applicable to all payment disputes. Follow procedures for resolving eligible out-of-network payment disputes to ensure timely final payment determinations.
• Collaborate with medical and legal professionals: Work closely with iMPROve Health’s pool of medical and legal professionals, leveraging their expertise to enhance the quality and accuracy of payment determinations.
• Adhere to all relevant compliance regulations: Ensure compliance with regulations including but not limited to HIPAA, FISMA, URAC, and CMS, maintaining the highest standards of privacy, confidentiality and security.
• Perform other duties as assigned: Take on additional responsibilities as needed to support the team and organization.

EDUCATION AND/OR EXPERIENCE:

• Juris Doctor (JD) from an accredited law school
• Bar admission in at least one US jurisdiction
• Background in healthcare law preferred
• Experience in medical coding and/or claims review, a plus
• Arbitration training by the American Arbitration Association, the American Health Law Association, or a similar organization, a plus
• No material financial or professional relationship to disputing parties

CERTIFICATES, LICENSES, REGISTRATION:

• Bar admission in at least one US jurisdiction

EOE/VET/Disability