Senior Provider Claims Dispute Specialist

Job not on LinkedIn

🔥 30 minutes ago

🇺🇸 United States – Remote

💵 $34 - $39 / hour

⏳ Contract/Temporary

🟠 Senior

👻 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.

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ZING. Enamel Whitening. Toothpaste, but magic.

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2023

💄 Beauty

🛒 Retail

🧘 Wellness

Beauty • Retail • Wellness

ZING is a toothpaste company that specializes in enamel whitening with a unique formulation that promises to dissolve stains, repair enamel, and reduce sensitivity. Proudly made in the UK, ZING's products are vegan, cruelty-free, and 100% recyclable. Their toothpaste is designed to be enjoyable to use while providing effective dental care, with a focus on natural ingredients and sustainability.

📋 Description

• Serve as a subject matter expert for provider dispute resolution policies, CMS requirements, and reimbursement methodologies • Provide guidance to Claims Operations, Provider Services, Configuration, and Compliance teams • Interpret provider contracts, reimbursement methodologies, and regulatory requirements for complex dispute determinations • Independently investigate and resolve escalated, high-dollar, highly complex, and regulatory-sensitive provider disputes • Perform payment reviews involving contract interpretation, authorization determinations, coding analysis, and benefit application • Respond to complex provider inquiries regarding claims adjudication and payment determinations • Resolve disputes accurately within regulatory and organizational timeframes • Maintain records of dispute research, determinations, correspondence, claim adjustments, recoveries, and tracking activities • Develop and maintain dispute trending reports and dashboards • Analyze dispute volume, root causes, financial impact, provider patterns, payment trends, and recurring operational issues • Identify payment errors, process gaps, training needs, and system configuration issues; escalate findings and support corrective action • Present findings and recommendations to leadership to reduce dispute volume and improve operational performance • Maintain regulatory knowledge and support implementation of changes affecting provider dispute processes • Apply HIPAA, CMS, and state-specific compliance requirements • Collaborate with Configuration, Provider Network, Provider Services, Quality, Compliance, Claims Operations, and IT teams • Participate in internal, external, CMS, and state regulatory audits • Identify and quantify financial impacts from payment inaccuracies and dispute trends • Assist with audit requests, documentation, research, and follow-up activities

🎯 Requirements

• Associate's degree in Healthcare Administration, Business Administration, Finance, Nursing, or a related field required; bachelor's degree preferred • Equivalent relevant experience accepted in lieu 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 • Three or more years of experience handling complex provider disputes or claims appeals • Experience interpreting provider contracts and reimbursement methodologies • Advanced knowledge of managed care claims operations, provider dispute resolution, Medicare Advantage, Medicaid, and applicable regulatory requirements • Knowledge of healthcare reimbursement methodologies, medical terminology, coding systems and groupers, including ICD-10, CPT, HCPCS, DRG, and ASC • Knowledge of claim forms including UB-04 and CMS-1500 • Ability to interpret provider contracts, reimbursement terms, benefits, authorizations, coding, and regulatory requirements and apply them to complex payment determinations • Strong analytical, critical-thinking, research, and problem-solving skills • Ability to identify discrepancies, determine root causes, quantify financial impact, and recognize provider or payment patterns • Ability to develop and maintain reports and dashboards and communicate findings clearly • Excellent written and verbal communication, consultation, and relationship-building skills • Strong organizational, time-management, and attention-to-detail skills • Intermediate proficiency in Microsoft Office applications, including Word and Excel

🏖️ Benefits

• Medical, Dental, and Vision • 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