NSA & State Arbitration Pathway Compliance Specialist

## Description

**Summary**

The No Surprises Act and State Arbitration Pathway Compliance Officer will lead the organization’s end-to-end compliance and operations for federal surprise billing protections and state surprise billing/arbitration pathways. This role ensures the organization correctly determines whether claims fall under the federal NSA pathway or state law (often differing for fully insured vs. self-insured plans), and that required notices, documentation, and filing deadlines are met—supporting dispute strategy without creating regulatory exposure.

This role is especially important for multi-state physician organizations with meaningful out-of-network exposure, where jurisdiction determination, timeline management, and complete dispute documentation materially affect both compliance risk and financial outcomes.

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**Why This Role Matters**

The No Surprises Act restricts surprise billing for certain emergency and non-emergency services and limits patients to in-network cost sharing for protected services. It also creates operational requirements for:

• Federal IDR (Independent Dispute Resolution)
• Good faith estimates (GFEs) for uninsured/self-pay patients
• Patient-provider dispute resolution (PPDR) readiness
• Disclosures, notice and consent workflows (where permitted)
• Strict documentation and timing obligations

• Because some claims may be governed by state processes (especially fully insured claims), the organization needs a dedicated owner for both federal and state pathways.
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• **Scope**

• Federal surprise billing compliance and disclosures
• Federal IDR operations (including open negotiation)
• Uninsured/self-pay GFE compliance and PPDR readiness
• State surprise billing laws and state arbitration/dispute pathways (multi-state)

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• **Core Responsibilities (Key Outcomes)**

• **Build and run the NSA compliance program:** policies, SOPs, controls, training, auditing, and escalation for surprise billing compliance across patient access, scheduling, coding, billing, managed care, and collections.
• **Maintain a state-by-state jurisdiction matrix:** when federal IDR applies vs. when state arbitration/payment rules control, including bifurcated rules for fully insured vs. self-funded plans.
• **Prevent missed deadlines:** implement workflows to identify eligible claims quickly after payer processing and manage negotiation/arbitration election windows.
• **Own federal IDR execution:** eligibility review, batching logic, open negotiation documentation, notice of initiation, offer package preparation, supporting documentation, fee tracking, and post-decision payment follow-up.
• **Coordinate state dispute/arbitration pathways:** state-specific filing rules, deadlines, templates, documentation standards, and escalation procedures.
• **Improve quality and defensibility:** partner with contracting, legal, RCM, and analytics to identify underpayments, confirm eligibility, reduce ineligible filings, and strengthen supporting documentation.
• **Audit and QA:** controls for patient notices, EOB-related workflows, cost-sharing calculations, NSA-sensitive billing edits, and dispute-file completeness.
• **Stay current and operationalize change:** monitor litigation, rulemaking, and agency guidance; translate updates into SOPs and training.
• **Train stakeholders:** patient access, clinicians, schedulers, coders, billers, collectors, managed care, and legal/compliance teams.
• **Report performance and risk:** volumes, open negotiations, arbitration yields, ineligible dispute rates, cycle times, fees, reversals, and material compliance incidents.

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• **Qualifications**
• **Required**

• Bachelor’s degree
• 3+ years in healthcare billing, compliance, managed care, payer disputes, legal operations, or provider reimbursement strategy
• Strong working knowledge of physician billing, remittance/EOB interpretation, underpayment identification, and dispute documentation

**Strongly Preferred**

• Direct No Surprises Act operational experience, including federal IDR submissions, open negotiation strategy, eligibility review, and out-of-network reimbursement issues
• Experience maintaining a multi-state legal applicability framework and working with counsel/advisors on jurisdiction/pathway decisions

**Preferred Certifications (optional)**

• CHC, CPCO, CPC, CPMA, CRCP, or similar (helpful but secondary to NSA/IDR operational expertise)

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**Success Profile**

A strong candidate combines regulatory judgment with hands-on operational execution, builds scalable workflows, meets strict deadlines, and aligns legal, RCM, and operations around a compliant, defensible, and financially sound dispute strategy across multiple states.