ABOUT THE ROLE

The IDR Revenue Cycle Manager is responsible for managing the strategy, documentation, procedural compliance, and financial performance of out-of-network claims that may qualify for open negotiation and Independent Dispute Resolution (IDR).

This role oversees the full lifecycle of eligible disputes, including claim and document review, eligibility assessment, deadline tracking, open negotiation, IDR initiation, offer development, preparation of supporting arguments and evidence, determination review, and payment reconciliation.

The ideal candidate has experience as a paralegal, attorney, legal operations professional, claims specialist, or regulatory compliance professional. This individual must be comfortable reviewing complex records, interpreting procedural requirements, preparing persuasive written submissions, managing strict filing deadlines, and developing dispute strategies based on the facts and financial value of each case.

The IDR Revenue Cycle Manager serves as the primary strategic partner for assigned clients and collaborates closely with Billing, IDR Specialists, Revenue Cycle team members, Compliance, Legal resources, leadership, and clients. The position is responsible for protecting filing rights, strengthening dispute submissions, maximizing lawful reimbursement opportunities, and ensuring that all cases are handled accurately and within applicable requirements.

ESSENTIAL FUNCTIONS

The IDR Revenue Cycle Manager’s responsibilities include, but are not limited to, the following:

IDR CASE STRATEGY AND OVERSIGHT

• Develop and manage a monthly IDR and out-of-network dispute strategy for each assigned client.
• Review claims, correspondence, payment records, remittance information, contracts, clinical documentation, and supporting materials to determine potential dispute eligibility.
• Assess cases based on procedural requirements, filing deadlines, available evidence, payer behavior, reimbursement opportunity, financial value, and likelihood of a favorable outcome.
• Oversee the full lifecycle of each eligible matter, from claim identification and open negotiation through IDR submission, determination, settlement, and final payment.
• Develop clear case theories and arguments based on the facts, documentation, reimbursement history, and applicable procedural requirements.
• Review and approve dispute offers, written statements, supporting documentation, exhibits, and case submissions before filing.
• Ensure that all representations made in dispute submissions are accurate, supported, and consistent with available records.
• Determine when additional information, documentation, or subject-matter review is required before proceeding.
• Escalate legally complex, high-risk, high-value, unusual, or precedent-setting cases to leadership, Compliance, or outside legal counsel.
• Ensure that favorable determinations and settlements are pursued through final payment and reconciliation.

LEGAL AND PROCEDURAL REVIEW

• Review applicable federal and state IDR procedures, notices, deadlines, filing requirements, and documentation standards.
• Interpret procedural rules and translate them into clear internal workflows and case requirements.
• Track open-negotiation periods, IDR initiation windows, response deadlines, payment deadlines, and other time-sensitive requirements.
• Ensure that all required notices, forms, statements, evidence, and supporting documents are prepared and submitted within applicable timelines.
• Review payer communications, determinations, settlement proposals, and requests for additional information.
• Identify procedural deficiencies, inconsistencies, unsupported positions, or missing information within case records.
• Maintain organized case files that clearly document the history, strategy, evidence, communications, deadlines, and resolution of each dispute.
• Coordinate with Compliance or legal counsel when a matter requires formal legal interpretation or advice.
• Avoid providing legal opinions or representing the organization as legal counsel unless the employee is appropriately licensed and authorized to do so.

CASE PREPARATION AND DOCUMENTATION

• Prepare clear, accurate, organized, and persuasive IDR submissions.
• Draft case summaries, factual narratives, negotiation positions, offer explanations, and responses to payer arguments.
• Compile supporting evidence, including claim forms, remittance advice, medical records, coding information, reimbursement data, provider credentials, patient acuity information, prior payment history, and relevant correspondence.
• Ensure that evidence directly supports the position and reimbursement amount presented in each dispute.
• Create case timelines and maintain detailed records of all communications, filings, determinations, payments, and follow-up actions.
• Review documents for consistency, completeness, accuracy, and compliance before submission.
• Maintain appropriate document naming, version control, confidentiality, and record-retention practices.
• Identify documentation gaps and coordinate with internal teams or clients to obtain missing information.
• Develop templates, checklists, evidence standards, and quality-control procedures for recurring dispute types.

NEGOTIATION AND DISPUTE MANAGEMENT

• Manage open-negotiation communications and settlement discussions with payers or their representatives.
• Develop negotiation positions based on case facts, available evidence, reimbursement history, payer trends, costs, and financial value.
• Prepare and communicate settlement recommendations to clients and leadership.
• Evaluate settlement offers and determine whether continued negotiation, IDR submission, escalation, or closure is appropriate.
• Maintain professional, fact-based, and well-documented communications throughout the dispute process.
• Identify recurring payer arguments and develop standardized responses supported by evidence.
• Track negotiation and dispute outcomes to improve future case selection and submission strategy.
• Ensure that settlement terms, determinations, and payments are accurately documented and reconciled.

REVENUE CYCLE AND FINANCIAL OVERSIGHT

• Maintain ownership of the financial performance of assigned IDR and out-of-network portfolios.
• Review accounts receivable, collections, denials, underpayments, write-offs, reimbursement trends, dispute expenses, and aging.
• Identify revenue leakage, underpayment patterns, unresolved awards, and missed recovery opportunities.
• Coordinate with Billers, Revenue Cycle Managers, IDR Specialists, and Team Leads to resolve upstream issues affecting claim eligibility or reimbursement.
• Verify that submitted claims, coding, documentation, billing information, and payer responses support the dispute position.
• Monitor outstanding determinations, settlements, and unpaid awards through final resolution.
• Evaluate filing costs and administrative expenses in relation to the expected and actual financial recovery.
• Recommend whether individual cases should be pursued based on financial value, procedural strength, risk, and available evidence.
• Ensure recoveries, settlements, fees, and adjustments are accurately recorded and reconciled.

CLIENT MANAGEMENT

• Serve as the primary point of contact for assigned clients regarding IDR matters and out-of-network dispute performance.
• Explain procedural requirements, case risks, deadlines, documentation needs, and potential outcomes in clear business language.
• Establish realistic expectations regarding case eligibility, timelines, settlement opportunities, expenses, and reimbursement.
• Present clear reporting on dispute volume, case status, outcomes, recoveries, aging, risks, and required client actions.
• Provide clients with strategic recommendations supported by case facts, payer history, and financial analysis.
• Request and follow up on documents, authorizations, attestations, and information required from clients.
• Communicate significant case developments, adverse determinations, procedural risks, and missed opportunities promptly.
• Maintain professional and trusted relationships through accurate advice, responsiveness, transparency, and consistent reporting.

REPORTING AND ANALYTICS

• Track eligible and potentially eligible claims.
• Track claims reviewed and eligibility decisions.
• Track open-negotiation notices, responses, offers, counteroffers, and settlements.
• Track IDR submissions, pending matters, determinations, dismissals, withdrawals, and payment status.
• Monitor win and settlement rates by payer, client, provider, procedure, dispute type, and case category.
• Track average additional recovery per case.
• Track total additional dollars recovered monthly and year to date.
• Track filing fees, administrative expenses, legal expenses when applicable, and other dispute-related costs.
• Monitor outstanding determinations and unpaid awards.
• Track missed deadlines, expired cases, incomplete cases, and lost filing opportunities.
• Analyze recurring payer positions, arguments, documentation requests, and determination patterns.
• Use case outcomes to strengthen future evidence selection, written arguments, settlement positions, and filing strategies.
• Prepare accurate reports for clients, leadership, Compliance, and operational teams.

COMPLIANCE AND QUALITY ASSURANCE

• Maintain complete, accurate, confidential, and audit-ready documentation for every dispute.
• Monitor changes to applicable IDR processes, filing requirements, documentation expectations, and procedural guidance.
• Communicate relevant process changes to leadership and affected team members.
• Ensure all submissions meet internal quality, evidence, documentation, and approval standards before filing.
• Conduct regular audits of active and closed cases.
• Identify missed deadlines, unsupported claims, inconsistent information, incomplete documentation, payment discrepancies, and process weaknesses.
• Develop corrective actions and prevention plans when quality or compliance issues are identified.
• Partner with Compliance, leadership, or legal counsel when interpretation, escalation, or formal legal review is required.
• Protect confidential, proprietary, financial, medical, and personally identifiable information.
• Ensure compliance with organizational policies and applicable privacy and security requirements.

TEAM LEADERSHIP AND DEVELOPMENT

• Coach IDR Specialists, Billers, and Revenue Cycle team members on eligibility, evidence collection, documentation standards, payer behavior, and dispute workflows.
• Establish clear ownership and accountability across every stage of the IDR process.
• Review team members’ case assessments, written submissions, documentation, and recommendations.
• Provide guidance on complex matters and assist with issue resolution and escalation.
• Develop knowledgeable team members who can independently manage routine cases.
• Identify training and performance gaps and collaborate with the Training Department on targeted education.
• Create and maintain standard operating procedures, case templates, submission guides, quality checklists, and reference materials.
• Provide feedback designed to improve legal writing, critical analysis, organization, accuracy, and deadline management.
• Promote a culture of accountability, confidentiality, professional judgment, and continuous improvement.

QUALIFICATIONS

Legal and Procedural Analysis

Ability to review complex facts, records, correspondence, and procedural requirements and determine how they apply to individual disputes.

Legal Research

Ability to research and monitor procedural rules, regulatory guidance, filing requirements, and changes affecting IDR and out-of-network disputes.

Legal Writing

Strong ability to prepare clear, persuasive, organized, fact-based, and well-supported written submissions.

Case Management

Ability to manage a large volume of active matters, deadlines, evidence, communications, filings, and follow-up actions.

Evidence and Document Review

Ability to identify relevant evidence, documentation gaps, factual inconsistencies, unsupported positions, and potential case risks.

Negotiation

Ability to develop and communicate reasonable settlement positions based on evidence, financial value, risk, and case strength.

Critical Thinking

Ability to evaluate competing positions, identify strengths and weaknesses, and recommend the most appropriate course of action.

Revenue Cycle Knowledge

Understanding of healthcare claims, reimbursement, accounts receivable, denials, underpayments, remittance information, collections, and payment reconciliation is strongly preferred.

Client Communication

Ability to explain complex procedural, financial, and dispute-related information clearly to clients, leadership, and operational teams.

Confidentiality and Professional Judgment

Ability to handle sensitive medical, financial, client, and legal information with discretion and sound professional judgment.

Time Management

Ability to manage competing priorities and complete accurate work within strict, non-extendable deadlines.

Organization and Attention to Detail

Ability to maintain structured and audit-ready files while accurately tracking multiple cases, deadlines, submissions, and outcomes.

Technical Skills

Proficiency in Microsoft Outlook, Word, and Excel. Experience with document-management systems, legal case-management systems, medical billing platforms, claims portals, IDR portals, and reporting tools is preferred.

SKILLS AND ABILITIES

• Strong legal research, writing, document-review, and case-management skills.
• Ability to understand and apply detailed procedural requirements.
• Ability to prepare persuasive arguments supported by facts and documentation.
• Ability to manage strict and overlapping filing deadlines.
• Ability to review claims, remittance information, correspondence, and supporting records.
• Ability to identify inconsistencies, weaknesses, missing evidence, and procedural risks.
• Ability to prioritize cases according to deadline, case strength, financial value, and recovery potential.
• Ability to develop negotiation, settlement, and dispute strategies.
• Ability to communicate confidently with clients, payers, leadership, and internal departments.
• Ability to maintain confidentiality and exercise appropriate professional judgment.
• Ability to work independently while recognizing when escalation or legal review is necessary.
• Ability to organize large volumes of information and maintain accurate case files.
• Ability to coach team members and improve the quality of case preparation.
• Ability to analyze case outcomes, payer behavior, reimbursement trends, and financial performance.
• Strong critical-thinking, problem-solving, and decision-making skills.
• Strong proficiency in Microsoft Word, Excel, Outlook, and related business applications.
• Ability to learn and effectively use new claims platforms, document systems, dispute portals, and reporting tools.

REQUIRED EXPERIENCE

• Minimum of three years of experience working as a paralegal, attorney, legal analyst, claims professional, legal operations specialist, regulatory specialist, or in a similar dispute-focused position.
• Experience managing legal, administrative, insurance, healthcare, reimbursement, or financial disputes is strongly preferred.
• Demonstrated experience reviewing complex records and preparing written arguments, case summaries, demand letters, submissions, or similar documents.
• Experience managing case files, evidence, correspondence, and strict procedural deadlines.
• Experience conducting legal, regulatory, or procedural research.
• Experience communicating with clients, opposing parties, insurance companies, government agencies, or other external stakeholders.
• Experience evaluating settlement positions, financial exposure, or dispute outcomes is preferred.
• Healthcare, medical billing, insurance claims, reimbursement, or revenue cycle experience is strongly preferred but may be learned by a candidate with significant legal dispute experience.
• Previous experience supervising, coaching, or reviewing the work of paralegals, legal assistants, claims specialists, or operational team members is preferred.

EDUCATION

One or more of the following is preferred:

• Juris Doctor degree.
• Bachelor’s degree in Legal Studies, Paralegal Studies, Business Administration, Healthcare Administration, Finance, or a related field.
• Associate degree or certificate in Paralegal Studies.
• Equivalent combination of relevant education and professional legal or dispute-management experience.

Admission to a state bar may be preferred for positions that require the employee to provide legal advice or perform functions reserved for licensed attorneys. However, active bar membership is not required when the role is structured as a legal operations, case-management, or paralegal position performed under appropriate organizational oversight.

KEY PERFORMANCE INDICATORS

Performance for this position may be measured using the following:

• Timely filing rate of 98% or higher.
• Review of 100% of identified potentially eligible claims.
• Client reports delivered 100% on time.
• Documentation accuracy maintained at 95% or higher.
• Missed deadline rate maintained below 2%.
• IDR win and settlement rates tracked by payer and client.
• Additional dollars recovered tracked monthly and year to date.
• Average additional recovery per case tracked monthly.
• Outstanding determinations and unpaid awards monitored at 30, 60, and 90 or more days.
• IDR filing and administrative expense-to-recovery ratio tracked monthly.
• Reduction in cases dismissed because of incomplete, inaccurate, or untimely submissions.
• Reduction in missed, expired, or unsupported dispute opportunities.
• Improvement in submission quality and routine-case independence among IDR team members.

WHAT SUCCESS LOOKS LIKE

• Potential disputes are reviewed thoroughly and accurately.
• Eligible matters are identified and filed within all required deadlines.
• Case submissions are clear, persuasive, complete, and supported by appropriate evidence.
• IDR win rates, settlements, and additional recoveries improve over time.
• Missed filing opportunities, expired cases, and preventable dismissals are minimized.
• Negotiations and settlements are supported by documented case analysis.
• Determinations and settlements are pursued through final payment and reconciliation.
• Clients receive clear, consistent, accurate, and timely reporting.
• Clients understand the strengths, risks, costs, timelines, and financial value of their IDR matters.
• Payer arguments and determination trends are used to improve future case strategy.
• IDR Specialists and operational team members independently manage routine matters using established procedures.
• High-risk or legally complex matters are escalated appropriately.
• The IDR Revenue Cycle Manager is able to focus on strategic case management, quality control, client performance, complex disputes, and high-value escalations.