At PRI, we’re passionate about driving integrity and advancing quality across the healthcare system. As a trusted leader in the industry, we’re tackling some of healthcare’s biggest challenges—improving compliance, advancing health equity, and enhancing quality and clinical outcomes while helping organizations improve care delivery and create meaningful change.
We believe that people are at the heart of healthcare, and focus on scalable, person-centered strategies that prioritize clinical excellence and evidence-based practices. Our work supports a broad network of stakeholders, including providers, patients, caregivers, payers, and regulators. We strive to enhance experiences, improve outcomes, and foster a healthier future for all.
If you’re looking to be part of a forward-thinking team that makes a difference, PRI is the place for you!
Job Title: Quality Assurance Analyst I – III (Independent Dispute Resolution Entity)
Position Description:
Under the direction of the Independent Dispute Resolution Entity (IDRE) Quality Assurance Manager, the Quality Assurance Analyst Independent Dispute Resolution Entity (IDRE) evaluates the assessments, decisions and outcome determinations rendered by the Insurance Specialists (Eligibility) and Health Insurance Specialists to assure that the appropriate standards have been applied and criteria have been met for IDR case acceptance, processing and payment adjudication. They will review the timeliness, accuracy and quality of case-specific assessment, documentation and communications related to specific steps in the IDR process including but not limited to request intake, acceptance and initiation of IDR process and payment determination prior to submission to stakeholder and CMS, checking for accuracy and completeness. They will evaluate/score reviewers both for production/quantity and precision/quality. In times of peak volume, they will also undertake IDRE reviews and act as either a Health Insurance Specialist or an Insurance Specialist (Eligibility).
Key Responsibilities:
· Conduct regular quality reviews of IDR disputes to ensure compliance with CMS.
· Develop and apply QA checklists and scoring guides to assess reviewer decisions, data entries, and communication accuracy.
· Review case documentation, timelines, and eligibility determinations for completeness, accuracy, and adherence to program process and procedures.
· Analyze trends, error types, and performance data to provide actionable insights to leadership and operational teams.
· Collaborate with reviewers to clarify QA findings, support training efforts, and promote continuous quality improvement.
· Ensure data integrity across systems, documentation, and federal portals (e.g., Federal IDR portal).
· Perform other duties as requested
Qualifications:
· Bachelor’s degree in a related field or equivalent experience.
· One year of experience with the IDRE Program. In lieu of one year of IDRE program experience 4 years of quality assurance experience
· 1–3 years of experience in quality assurance, compliance, or auditing—preferably in healthcare, regulatory, or dispute resolution environments.
· Familiarity with healthcare billing, provider/payer relationships, and dispute adjudication is a plus.
· Exceptional attention to detail and analytical thinking.
· Proficiency in Microsoft Outlook, Excel, Word.
· Ability to work independently and collaboratively in a fast-paced, compliance-driven environment
· Ability to be discrete and maintain confidentiality
Preferred Skills:
· Experience working with or within a CMS-certified IDR entity.
· Strong understanding of the No Surprises Act, especially the IDR process, timelines, and regulatory guidance preferred.
· Knowledge of CMS federal audit protocols and performance standards.
· Experience with case management platforms and automated QA tracking systems.
· Excellent written and verbal communication skills for reporting, documentation, and feedback delivery.
EEO Statement:
Provider Resources, LLC is an Equal Opportunity Employer. We do not discriminate against qualified applicants based upon any protected group status, including but not limited to race, religion, color, creed, sex (including breastfeeding and related conditions), gender identity/gender expression, pregnancy (including childbirth and related conditions), national origin, ancestry, age, marital status, military or veteran status, sexual orientation, genetic information, physical or mental disability or medical condition as defined by applicable equal opportunity laws. Any request for accommodation can be directed to Human Resources.
Benefits and Compensation
Provider Resources provides a competitive benefits package that includes access to Medical, Dental, and Vision Insurance, Life Insurance, Disability, Health Savings Account (HSA), Flexible Spending Accounts (FSA), Critical Illness, Accident, Legal and ID Theft, 401k plan, PTO, and ESPP (Employee Stock Purchase Plan).
The final salary offered will be dependent on several factors that include but are not limited to relevant previous experience including duration and type of experience within the industry, education, and internal equity.
HUBZone Preference: Preference will be given to individuals who reside in, or are willing to relocate to, a recognized HUBZone area. For more information, visit Go to www.sba.gov/hubzone