Provider Dispute Resolution Analyst

Job not on LinkedIn

🔥 1 minute ago

🏄 California – Remote

🏄 California – Remote

💵 $32 - $44 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

🚫👨‍🎓 No degree required

👻 Ghost score 0%

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Gold Coast Health Plan

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2011

At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

📋 Description

• Investigate, analyze, and resolve provider disputes in accordance with regulatory requirements, contractual obligations, organizational policies, and claims processing guidelines • Research claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation • Process provider disputes accurately within established regulatory timeframes • Communicate with providers and internal business partners regarding dispute status, resolution decisions, and additional information requests • Document dispute findings, research, determinations, and claim adjustments in designated systems • Coordinate with Claims, Configuration, Provider Relations, Utilization Management, Finance, Information Technology, and other departments • Identify claim processing errors, payment discrepancies, system issues, and recurring operational concerns, escalating as appropriate • Monitor assigned inventory to ensure productivity, quality, and compliance standards • Maintain current knowledge of provider contracts, reimbursement methodologies, claims adjudication practices, regulations, and departmental policies • Participate in departmental meetings, training, quality improvement initiatives, and assigned projects • Perform other duties as assigned

🎯 Requirements

• High School Graduate or General Education Degree (GED) • Knowledge of Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations • Knowledge of medical billing and coding methodologies, including 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 • Knowledge of Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices • Knowledge of state and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare (CMS), and DMHC requirements • Knowledge of provider contracting concepts, DOFR, reimbursement methodologies, and health plan contractual obligations • Knowledge of claims processing systems, encounter processing concepts, and Microsoft Office applications • Two (2) years of progressively responsible experience in health care claims processing, claims operations, encounter operations, managed care, provider reimbursement, or a related healthcare operational environment preferred • Medi-Cal/Medicaid managed care experience strongly desired • Advanced computer skills in MS Office products • A valid and current Driver's License, Auto Insurance, and professional licensure(s)