Evry Health

• Provide a high degree of customer service and professionalism when interacting with the patients of providers via the phone or email; ability to empathize and diffuse difficult situations professionally and in a caring manner • Assist members with detailed provider searches utilizing network look-up tools • Assist members navigating our digital programs and serve as a conduit for escalations and questions • Contact provider offices or facilities to obtain needed prior authorization pieces such as additional medical records, forms, facility location or Tax ID numbers for claims billing • Assist with claims work such as adjusting site of service • Protect/observe patient privacy and confidentiality, per external regulatory requirements (HIPAA) and internal policy and procedures • Ensures compliance with applicable URAC and NCQA accreditation guidelines and state and federal regulations

• Development of an adequate provider network within assigned geographic markets. Includes Negotiating and renegotiating contracts with physicians and provider groups and facilities • Responsible for collecting roster updates and standardizing information received with Analytics and IT teams • Tracking and coordinating notification of effective date with the credentialing CVO • Maintenance and management of the network in accordance with regulatory time, distance and choice requirements • Building and maintaining relationships with contracted providers, including responding to inquiries related to contract status, roster corrections and matters related to information accuracy • Routinely running and monitoring of various reports to ensure all necessary compliance requirements are being met and maintained, and identifying targets to address emergent gaps • Accurate maintenance of Salesforce or similar contract tracking and activity system • Reporting to leadership the current status, risks, and potential opportunities in area of responsibility on a regular basis • Working with analytics and actuarial team(s), compile and analyze provider and hospital fee schedules to benchmark against goals and assist with the medical economics reporting • Performs other duties as required

• Manage provider disputes from initial intake through final resolution, ensuring adherence to regulatory timeframes, state prompt-pay requirements, and internal SLAs. • Review and validate all incoming dispute submissions to confirm completeness; identify and communicate deficiencies to providers in a timely and professional manner. • Accurately log, track, and maintain dispute inventories within Salesforce or applicable case management systems, ensuring real-time case status visibility. • Prioritize and manage a high-volume caseload while maintaining accuracy, thoroughness, and compliance with established turnaround standards. • Identify when cases require escalation to senior staff, management, legal, or other internal departments and facilitate appropriate handoffs. • Conduct thorough, independent research into disputed claims by reviewing EOBs, remittance advice, claim histories, coordination of benefits (COB) determinations, eligibility records, provider contracts, fee schedules, and applicable benefit language. • Investigate root causes of payment discrepancies, including contract misapplication, coding errors, system configuration issues, benefit plan misinterpretation, and eligibility discrepancies. • Evaluate new information and documentation submitted by providers against the original claim decision. • Review all relevant information — including the original determination rationale, supporting documentation, and any new evidence — to independently assess whether a reversal or modification of the original decision is warranted. • Apply knowledge of CPT, HCPCS, ICD-10, revenue codes, and billing guidelines to evaluate the validity of disputed charges and determine appropriate payment outcomes. • Analyze and interpret complex provider requests, identify the specific issue(s) raised, and determine the most appropriate and complete course of action for resolution. • Review applicable state and federal regulations, internal policies, and provider contract terms to support well-reasoned dispute determinations. • Gather, organize, and evaluate all pertinent documentation — including claim history, supporting provider correspondence, and system notes — to build a complete case record prior to issuing a determination. • Initiate and process claim adjustments for disputes determined to be valid, ensuring corrections are applied accurately and completely in claims processing systems. • Remediate impacted claims identified through the dispute process, including bulk adjustments when systemic errors are identified. • Verify that adjusted claims are reprocessed in accordance with the correct contract, benefit, and coding guidelines, and that resulting payments are accurately issued. • Validate adjustment outcomes post-processing and communicate finalized results to providers in a clear and timely manner. • Document all adjustment actions, rationale, and outcomes in the case management system for audit-readiness and regulatory reporting. • Draft clear, professional, and well-supported written responses to providers for all dispute determinations — both upheld and overturned — ensuring that all points raised by the provider are directly and thoroughly addressed. • Compose acknowledgment letters, resolution letters, and reconsideration notices in accordance with regulatory requirements and internal communication standards. • Ensure all written correspondence is accurate, concise, free of jargon, and appropriate for the intended audience, whether a billing department, practice manager, or hospital administrator. • Maintain consistent, professional communication throughout the dispute lifecycle, including follow-up correspondence when additional information is requested. • Serve as a knowledgeable resource for providers navigating the dispute and adjustment process, responding to inquiries in a timely and informative manner. • Analyze dispute and adjustment trends to identify patterns in claim adjudication errors, billing code misapplication, contract misinterpretation, or system configuration issues. • Partner with the VP of Operations to develop and implement corrective action plans based on findings from dispute and adjustment activity. • Translate dispute data and root cause analysis into actionable insights and present recommendations to leadership to improve workflows, reduce error rates, and strengthen the overall claims process. • Collaborate with Customer Service leadership to identify training gaps and support the development of educational materials related to billing, coding, claim submission, and dispute processes for the CSRs. • Contribute to the development and maintenance of department policies, procedures, and job aids. • Maintain detailed, audit-ready case documentation for all disputes, adjustments, within Salesforce or the designated case management platform. • Ensure all dispute activity complies with applicable state and federal regulations, including ERISA requirements, state prompt-pay statutes, Texas Department of Insurance (TDI) rules, and internal policies. • Support internal and external audits by providing complete and organized dispute records, resolution documentation, and reporting as requested. • Stay current on regulatory changes affecting provider dispute resolution, claims payment requirement processes at both the federal and state level. • Adhere to all privacy, confidentiality, and data security requirements in the handling of provider and member information.

• Risk Assessment: Evaluate and analyze health insurance applications to determine the risk they pose, helping to set premium rates that are both fair and competitive. • Claims Analysis: Interpret and analyze underlying claims experience to inform underwriting decisions and policy adjustments. • Collaboration: Work closely with sales teams to develop competitive insurance products and strategies, ensuring alignment with company goals and client needs. • Policy Development: Assist in the development of insurance policies or suggest changes to existing policies that balance the needs of market with the risk to the insurance company. • Regulatory Compliance: Stay updated with changes in legislation and regulations that may affect the product design and underwriting considerations. • Documentation: Maintain accurate and detailed records of policies underwritten and decisions made, tracking concessions and experience. • Communication: Coordinate with brokers and agents to gather additional information or to explain underwriting decisions.

• Configure, monitor, and troubleshoot inbound and outbound HIPAA 834 (Benefit Enrollment and Maintenance) transaction files with trading partners, employers, and TPAs • Validate 834 file structures for compliance with X12 5010 standards, identifying and resolving segment errors, loop discrepancies, and rejected transactions • Coordinate with trading partners to resolve enrollment exchange issues and ensure timely, accurate file transmission • Perform systematic validation of member enrollment records against source documents, 834 transactions, and plan eligibility rules • Identify data anomalies, duplicate records, coverage gaps, and demographic inconsistencies • Execute data quality audits on a scheduled and ad-hoc basis, documenting findings and remediation steps • Ensure enrollment data aligns with plan effective dates, benefit periods, and group contract terms • Accurately enter and update member demographic, eligibility, and coverage data across the web UI enrollment portal and the claims processing system • Process member adds, terminations, changes, and reinstatements in a timely manner in compliance with CMS and ACA guidelines • Maintain supporting documentation for all manual data changes per audit and compliance standards • Lead targeted data cleanup projects to address backlogs, legacy migration issues, and discrepancies identified through audits or operational escalations • Write and execute SQL queries against enrollment and member databases to identify, extract, and correct data issues • Collaborate with the engineering team on bulk update scripts and data remediation workflows • Partner with engineering, claims, and population health teams to surface enrollment data issues affecting downstream claim adjudication, reporting, and care management workflows • Support compliance and reporting requirements including ACA 1095-B and CMS enrollment submissions • Communicate enrollment discrepancies and resolution status to internal stakeholders and external partners

Title: Sr. Software Engineer (Node) Location: Dallas-Fort Worth, Texas Department: Engineering – Shared Services - IT Job Description: Roles and Responsibilities - System Architecture & Design: Lead the design and implementation of scalable and maintainable systems, ensuring alignment with business requirements and technical standards. - Development & Coding: Write efficient and maintainable code using Node 20 LTS (back-end), Next 15+ (Backend + Front end), React 19+, React Native 0.80+, and Expo SDK 54+ technologies, following best practices for software development, including test-driven development and continuous integration. Primary focus will be on backend services, RESTful API development, Next.js API routes, and SQL database design and optimization. - Backend & Database Development: Design and optimize SQL database schemas, write complex queries, and implement ORMs (Prisma, TypeORM, Sequelize, or similar). Build and maintain robust backend services using Express.js, Fastify, or similar Node.js frameworks. - API Design & Documentation: Create well-documented RESTful APIs using OpenAPI/Swagger specifications, ensuring consistency and ease of integration for frontend and mobile applications. - Technical Leadership: Provide technical guidance and mentorship to junior engineers, conducting code reviews, and ensuring adherence to established coding standards and practices. - Performance Optimization: Identify and resolve performance bottlenecks in systems, databases, and APIs, ensuring high availability and reliability of services. - Collaboration: Work closely with cross-functional teams, including .NET core developers and product managers, to deliver software solutions. - Documentation: Create and maintain technical documentation for systems, processes, and codebases to ensure knowledge sharing and continuity. - Security & Compliance: Implement and enforce security best practices, ensuring that backend systems are secure and compliant with relevant regulations and standards. - Problem Solving: Troubleshoot and resolve complex technical issues, providing timely and effective solutions to minimize downtime and ensure smooth operation of systems. - Cloud & DevOps: Deploy and manage applications on Azure cloud platform, implement CI/CD pipelines, and work with containerization technologies (Docker). Familiarity with GitHub actions and workflows. - Experience and Skills Desired - Bachelor's degree in Computer Science, Engineering, or a related field (or equivalent experience). - 10+ years of professional experience in software development, with a focus on Node and React technologies, primarily in backend development. - Strong backend expertise: Deep proficiency in Node.js 20 LTS for backend development, including experience with Express.js, Fastify, NestJS, or similar frameworks. - Database proficiency: Advanced SQL skills with PostgreSQL, MySQL, or SQL Server, including schema design, query optimization, indexing, and performance tuning. Experience with ORMs such as Prisma, TypeORM, or Sequelize. - API development: Proven experience designing, building, and documenting RESTful APIs. Familiarity with GraphQL or tRPC is a plus. - Experience with full-stack development and back-end technologies (.NET core, Azure, C#, etc.) - Proficiency in Node 20 LTS (back-end), Next 15+ (Backend + Front end), React 19+, React Native 0.80+, and Expo SDK 54+ technologies. - Azure cloud platform: Experience with Azure services (App Service, Azure Functions, Azure SQL Database, Blob Storage, API Management, etc.). - DevOps & containerization: Hands-on experience with Docker, CI/CD pipelines (Azure DevOps, GitHub Actions), and Azure Container Instances or Azure Kubernetes Service. - Testing: Experience with backend testing frameworks (Jest, Mocha, Supertest) and test-driven development practices. - Version control: Strong Git workflow experience, including pull request reviews, branching strategies, and collaborative development. - Understanding of services architecture, distributed systems, and microservices patterns. - Authentication & security: Experience implementing authentication and authorization (JWT, OAuth, Azure AD, or similar). - Monitoring & logging: Experience with Sentry for error tracking and Azure Application Insights for application monitoring and performance analysis. - Caching & message queues: Experience with Redis for caching and BullMQ for job queue management. - Bonus: Healthcare software development experience - Telecommuting Requirements - This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas. While this position is remote, candidates must live in the Dallas-Fort Worth, TX area or be willing to relocate. - Company business hours are weekdays 9-5 CST. - Required to have a dedicated work area established that is separate from other living areas and provides information privacy. - Ability to keep all company sensitive documents secure. - Must live in a location that receives an existing high-speed internet connection/service. - Benefits - Competitive salary - Comprehensive health, dental, and vision insurance as well as life and disability - Retirement savings plan with company match - Generous time off/vacation - Professional development opportunities - Flexible work environment - We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.

• System Architecture & Design: Lead the design and implementation of scalable and maintainable back-end systems. • Development & Coding: Write efficient and maintainable code using .NET technologies. • Cloud Infrastructure: Design, deploy, and manage cloud-based services and infrastructure on Microsoft Azure. • Technical Leadership: Provide guidance and mentorship to junior engineers. • Performance Optimization: Identify and resolve performance bottlenecks in backend systems. • Collaboration: Work closely with cross-functional teams to deliver software solutions. • Documentation: Create and maintain technical documentation for systems. • Security & Compliance: Implement and enforce security best practices. • Problem Solving: Troubleshoot and resolve complex technical issues.

• Deliver engaging, interactive training sessions via Teams platform for new hires and tenured staff covering product knowledge, soft skills, and systems navigation. • Lead structured onboarding programs covering Evry Health’s products, systems, workflows, policies, and member-centric service standards. • Design and facilitate live role-play scenarios that mirror real customer interactions, claims inquiries, and escalation situations. • Combine synchronous instructor-led sessions with asynchronous e-learning modules, job aids, and recorded content. • Administer knowledge checks, quizzes, and skills assessments to confirm learner readiness before live deployment. • Monitor staff performance; identify training gaps and deploy targeted interventions to address deficiencies quickly. • Collaborate with Operations leadership to craft clear, timely change communications that prepare agents for upcoming system or workflow transitions. • Train staff on end-to-end claims lifecycle, adjudication, issue identification and remediation, including testing outcomes, denial, adjustment, and dispute procedures. • Deliver training on Texas Insurance Code Chapter 1467, prompt-pay requirements, IDR processes, and CMS guidelines. • Provide foundational instruction on ICD-10, CPT, HCPCS, and modifier usage as it relates to claims review and provider disputes. • Train agents on Evry Health’s call-handling protocols and quality expectations. • Coach staff on professional, empathetic communication. • Reinforce 1-business-day (member) and 2-business-day (provider) correspondence turnaround standards and documentation requirements. • Build staff confidence in identifying, documenting, and escalating complex or sensitive cases to supervisory and clinical teams. • Align training content with QA audit rubrics covering call quality, case accuracy, and documentation standards. • Develop and maintain SOPs, job aids, desk-top procedures, e-learning modules, and quick-reference guides for all operational workflows. • Build comprehensive knowledge assessments with scoring rubrics aligned to benefit program content and operational standards. • Promptly revise training materials in response to regulatory changes, system updates, or operational policy revisions. • Upload, organize, and track training completion records. Generate training completion reports, assessment score summaries, and gap-analysis data for Operations leadership.

• Provide accurate and thorough information on commercial health plan benefits, eligibility, and claims. • Handle inbound and outbound calls as well as respond to email inquiries from customers. • Develop processes, call scripts, metrics, and desktop procedures. • Deliver an exceptional customer service experience to Evry members and providers. • Partner with senior leadership daily. • Work effectively in a virtual work environment.

• Provide accurate and thorough information on commercial health plan benefits, eligibility, and claims. • Handle inbound and outbound calls as well as respond to email inquiries from customers. • Develop processes, call scripts, metrics, and desk top procedures. • Deliver exceptional customer service experience to Evry members and providers. • Partner with senior leadership daily.