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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.

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.

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)

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.

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)

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.