Senior Provider Dispute Resolution Analyst

Job not on LinkedIn

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $38 - $53 / hour

⏰ Full Time

🟠 Senior

🧐 Analyst

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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 highly complex provider disputes involving reimbursement methodologies, contractual interpretation, regulatory requirements, and claims adjudication • Provide technical guidance and support to Provider Dispute Resolution Analysts • Research complex claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation • Resolve escalated provider disputes and collaborate with internal departments on provider payment issues • Identify dispute trends, payment discrepancies, claim processing defects, and operational issues; recommend corrective actions and process improvements • Perform quality reviews and provide coaching and feedback • Assist with onboarding, training, and mentoring new staff • Monitor regulatory requirements, provider contracts, reimbursement methodologies, and organizational policies • Prepare reports, analyses, and recommendations concerning disputes, payment trends, operational performance, and compliance • Participate in cross-functional meetings with Claims, Configuration, Provider Relations, Finance, Compliance, Information Technology, and other departments • Support initiatives improving provider experience, operational efficiency, payment accuracy, and regulatory compliance • Perform other duties as assigned

🎯 Requirements

• High School Diploma or General Education Degree (GED) required • Five (5) years of progressively responsible experience in healthcare claims processing, provider dispute resolution, claims analysis, provider reimbursement, or a related managed care or health insurance environment • Experience researching and resolving highly complex provider disputes, claims adjudication, reimbursement, contractual interpretation, or provider payment issues • 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 applicable state and federal healthcare regulations, including Medi-Cal, Medicare (CMS), and DMHC requirements • Knowledge of provider contracting concepts, DOFR, reimbursement methodologies, and contractual obligations • Knowledge of claims processing systems, encounter processing concepts, and Microsoft Office applications • Advanced computer skills in MS Office products • A valid and current Driver's License, Auto Insurance, and professional licensure(s)