Senior Provider Dispute Resolution Analyst

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

📋 Description

• Investigate, analyze, and resolve intricate provider disputes related to reimbursement methodologies, contractual interpretations, regulatory compliance, and claims adjudication.

• Offer technical guidance and support to Provider Dispute Resolution Analysts.

• Conduct research on complex claims, payment histories, benefits, authorizations, provider agreements, reimbursement methodologies, and relevant documentation.

• Address escalated provider disputes while collaborating with internal departments on provider payment concerns.

• Identify trends in disputes, payment inconsistencies, claim processing defects, and operational challenges; recommend corrective measures and process enhancements.

• Execute quality reviews and provide coaching and feedback.

• Assist in the onboarding, training, and mentoring of new team members.

• Monitor regulatory obligations, provider contracts, reimbursement methodologies, and organizational policies.

• Compile reports, analyses, and recommendations pertaining to disputes, payment trends, operational performance, and compliance.

• Engage in cross-functional meetings with Claims, Configuration, Provider Relations, Finance, Compliance, Information Technology, and other departments.

• Support initiatives aimed at enhancing provider experience, operational efficiency, payment accuracy, and regulatory compliance.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• A High School Diploma or General Education Degree (GED) is required.

• A minimum of five (5) years of progressively responsible experience in healthcare claims processing, provider dispute resolution, claims analysis, provider reimbursement, or a similar managed care or health insurance setting.

• Proficient in researching and resolving complex provider disputes, claims adjudication, reimbursement, contractual interpretation, or provider payment issues.

• Familiarity with Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations.

• Understanding of medical billing and coding methodologies, such as CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms.

• Knowledge of claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows.

• Awareness of Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices.

• Understanding of relevant state and federal healthcare regulations, including Medi-Cal, Medicare (CMS), and DMHC requirements.

• Knowledge of provider contracting concepts, DOFR, reimbursement methodologies, and contractual obligations.

• Familiarity with claims processing systems, encounter processing concepts, and Microsoft Office applications.

• Advanced computer proficiency in MS Office products.

• Possession of a valid and current Driver's License, Auto Insurance, and relevant professional licensure(s).

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment promoting teamwork and collaboration.