Senior Provider Claims Dispute Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as a subject matter expert in provider dispute resolution policies, CMS regulations, and reimbursement methodologies.

• Offer guidance to Claims Operations, Provider Services, Configuration, and Compliance teams.

• Analyze provider contracts, reimbursement methods, and regulatory requirements for complex dispute resolutions.

• Independently conduct investigations and resolve escalated, high-value, highly complex, and regulatory-sensitive provider disputes.

• Execute payment reviews that involve contract interpretation, authorization determinations, coding analysis, and benefit application.

• Address complex provider inquiries related to claims adjudication and payment decisions.

• Resolve disputes accurately within regulatory and organizational time constraints.

• Keep records of dispute research, resolutions, correspondence, claim adjustments, recoveries, and tracking activities.

• Create and maintain reports and dashboards for tracking dispute trends.

• Analyze dispute volume, root causes, financial impacts, provider behaviors, payment trends, and ongoing operational issues.

• Identify payment errors, process deficiencies, training requirements, and system configuration problems; escalate findings and facilitate corrective actions.

• Present findings and suggestions to leadership to minimize dispute volume and enhance operational efficiency.

• Stay informed on regulatory changes and assist in implementing updates that impact provider dispute processes.

• Adhere to HIPAA, CMS, and state-specific compliance mandates.

• Collaborate with Configuration, Provider Network, Provider Services, Quality, Compliance, Claims Operations, and IT teams.

• Engage in internal, external, CMS, and state regulatory audits.

• Identify and assess financial impacts resulting from payment inaccuracies and dispute patterns.

• Support audit requests, documentation, research, and follow-up efforts.

⛳️ Requirements

• An Associate's degree in Healthcare Administration, Business Administration, Finance, Nursing, or a related field is required; a bachelor's degree is preferred.

• Relevant equivalent experience may be accepted in place of the required degree or diploma.

• Five to seven years of progressive experience in Medicare Advantage claims operations, provider dispute resolution, appeals, payment integrity, or healthcare reimbursement.

• At least three years of experience in managing complex provider disputes or claims appeals.

• Proficient in interpreting provider contracts and reimbursement methodologies.

• Advanced understanding of managed care claims operations, provider dispute resolution, Medicare Advantage, Medicaid, and relevant regulatory requirements.

• Familiarity with healthcare reimbursement methodologies, medical terminology, coding systems, and groupers, including ICD-10, CPT, HCPCS, DRG, and ASC.

• Knowledge of claim forms such as UB-04 and CMS-1500.

• Capability to interpret provider contracts, reimbursement terms, benefits, authorizations, coding, and regulatory requirements for complex payment determinations.

• Strong analytical, critical-thinking, research, and problem-solving abilities.

• Proficient in identifying discrepancies, determining root causes, quantifying financial impacts, and recognizing provider or payment trends.

• Skillful in developing and maintaining reports and dashboards and effectively communicating findings.

• Exceptional written and verbal communication, consultation, and relationship-building abilities.

• Strong organizational, time-management, and detail-oriented skills.

• Intermediate proficiency in Microsoft Office applications, including Word and Excel.

🏝️ Benefits

• Medical, Dental, and Vision coverage.

• Employer-Paid Life Insurance.

• Paid Maternal Leave.

• Paid Paternal Leave.

• 401(K) match up to 4%.

• Paid Time Off.

• Employee Assistance Programs.

• Supplemental benefits, including Spouse Insurance, Pet Insurance, Critical Illness coverage, and ID Protection.