Provider Claims and Dispute Resolution Specialist

Location: Monterey Park, CA
Date Posted: 03-11-2019
Provider Claims and Dispute Resolution Specialist ​ – Third Party Administrator
Monterey Park, CA (Suburb east of LA)
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 3-4 months, or longer! ***

Provider Claims and Dispute Resolution Specialist ​Job Summary: 
  • Intake, screen, and adjudicate provider disputes that are submitted for both Facility and Professional services rendered for all products; Medicare, Medi-Cal, Commercial, PACE Lines of Business.
  • Read and interpret the provider’s dispute in order to identify how to make the provider whole in regards to the payment expected.
  • Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.
  • Read and interpret provider contracts to ensure payment/denial accuracy.
  • Read and interpret Medi-Cal and Medicare Fee Schedules.
  • Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.
  • Maintain an error accuracy of under 1%.
  • Communicate with Claims Management for provider, fee schedule, eligibility, authorization, or system issues.\
  • Identify root cause in order to avoid and/or minimize future provider disputes.
  • Assist with business rules and training in order for the Claims Department to become more efficient and accurate.
  • Coordinate with the Recovery Department for any identified over-payments.
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Provider Claims and Dispute Resolution Specialist ​ Background:   
  • Requires an education level of at least a high school diploma or GED.
  • Prefer, but does not require, a Certified Health Data Analyst (CHDA) or similar.
  • At least 1-2 years experience processing on-line claims in a managed care environment.
  • Proficient knowledge of the reading of a CMS-1500 and UB-04 form.
  • Around 2-3 years in member services or health data analysis experience, preferably in managed care environment.
  • Knowledge of health care delivery system, Medicaid/Medicare, related state programs, and dual eligibility programs required.
  • Strong working knowledge of concepts, practices, and procedures related to managed care / practice management.
  • Established experience with database management system. 
  • Basic familiarity with Medical terminology is required.
  • Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.
623.201.8732 (CALL – TEXT – FAX)
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