Provider Dispute Resolution Coordinator, Intermediate

Your Role

The Provider Dispute Resolution Team is looking for an Intermediate Provider Dispute Resolution Coordinator that can research, review and adjust high priority and high dollar provider grievances, appeals and complaints, while clarifying issues and educating providers in the process for the No Surprise Billing mandate. The Intermediate Provider Dispute Coordinator will report to the PDR Operations Manager. In this role, the coordinator should be able to make independent decisions and appeal determinations. The candidate should effectively manage their time and prioritize their workload to ensure compliance timeframes and project deadlines are met.

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination.
• Requires claims processing, including adjustments, interest accuracy proficiency, general suspense and back-end claims experience.
• Strongly preferred experience in Commercial LOB claims and/or appeals
• Preferred experience in Medi-Cal and/or Medicare LOB claims and/or appeals
• Preferred experience in No Surprise Billing
• Preferred knowledge of applicable legislation/regulations and compliance.
• Preferred knowledge of following systems - Facets, DocDNA, Smartcomm, Documentum, CLMS, CMS Pricers = 3M Pricer, DRG Pricer, SNF Pricer, CareWebQI.
• Strong skill set of Microsoft Office applications
• Demonstrated experience with free format letter writing