Provider Dispute Resolution Claims Examiner II

Permanent Placement Opportunity!

Job Title: Provider Dispute Resolution Claims Examiner II

Location: Los Angeles, CA

Salary Range: USD $29.22 $36.52 / hr

Job Summary

The Provider Dispute Resolution Claims Examiner II is responsible for:

• The accurate analysis and resolution determination of Provider Disputes from all sources.
• Assist in the resolution of eligibility, benefit, contracting, and payment schedule issues.
• Handle and document resolution to escalated telephone and written appeals.
• Ensuring all PDR documents are processed timely with timely submission of all acknowledgement and resolution letters.
• Timely processing of complex PDR claims for all lines of business Auditing claims for excessive charges, duplicates, unbundling, and medical up coding
• Maintaining department databases used for report production and tracking on-going work
• Assisting management with in-house and on-site training as offered to employees and providers.
  
  

Duties

Processing claims for all products. Claims will be accurately processed within the applicable contractual or regulatory time frames. Meet production and quality standards set by PDR Claims Department Management. (30%) Resolving member and provider claims payment disputes. Issues will be resolved within the specific time frame as required by regulatory agencies and as supported by departmental policies. (20%) Performs special projects and ad-hoc reporting as necessary. Projects will be complete and reports will be generated within the specific time frame agreed upon at the time of assignment. (15%) Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (10%) Working with internal departments to resolve issues preventing claims processing or to enhance processing effectiveness. May assist in testing, changing, analyzing and reporting of specific enhancements. (15%) Perform other duties as assigned. (10%)

Education Required

Associate's Degree In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree

Experience

Required:

Preferred

At least 0-2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes. Preferred:

Experience processing PDR documents. Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.

Skills

Required:

• Ability to operate PC-based software programs or automated database management systems.
• Strong communication skills with excellent analytical and problem- solving skills. Ability to self-manage in a fast-paced, detail-oriented environment.
• Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials(PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.
• Moderate knowledge of Microsoft Word and Excel.
• Persuasion Skills: Persuading co-workers and management to accept recommendations for work flow or procedural changes to support process improvement efforts. In cases of provider payment dispute, Convincing the provider that their claims have been handled properly bases on the provider contract or regulatory guidelines.