Provider Dispute Resolution Specialist at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Provider Dispute Resolution Specialist

Position Summary:

The Provider Dispute Resolution Specialist ("Specialist") is responsible for processing provider appeals and disputes accurately and timely. The Specialist assesses and completes appropriate documentation for tracking/trending data. Conducts all pertinent research in order to respond and process incoming provider appeals and disputes in accordance with all established CMS Medicare Advantage regulatory, contractual and departmental guidelines. The Specialist processes the claim(s) accordingly within the claim system while following department processes. Interface with internal departments and external resources and organizations. Prepares and assist with departmental reports as needed.

General Duties/Responsibilities:

(May include but are not limited to)

1. Properly distinguishes between a provider dispute and a provider appeal. Confirm each provider appeals are correctly identified for appropriate tracking and reporting
2. Updates tracking system to ensure cases are processed timely and appropriate actions are taken
3. Reviews and processes provider appeal and dispute determinations according to CMS, contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.
4. Corresponds with delegated entity as needed to obtain appropriate records or payment information
5. Prepares appropriate documentation and submit to IRE when provider appeals result in adverse determination and/or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
6. Processes/Adjudicates claim(s) according to departmental procedures
7. Meets and consistently maintains quality and productivity standards as defined by the Management.
8. Identifies denial or payment variance trends and escalates to department management as appropriate for training opportunities and corrective action.
9. Assists in preparing and reviewing cases for regulatory and other health plan audits.
10. Actively participates in ongoing training to support company and department initiatives.
11. Supports department initiatives in improving processes and workflow efficiencies
12. Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.
13. Complies with company's time and attendance policy.
14. Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
15. Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.
16. Performs additional related duties as assigned by Management

1. Minimum Experience:

• 3+ years experience processing Medicare Advantage provider appeals from all types of providers (hospitals, physicians, ancillary)
• 3+ years experience in examining all types of medical claims, preferably Medicare Advantage claims

1. Education/Licensure:

• High School Diploma required
• Bachelor's Degree in related field, a plus

1. Other:

• Working knowledge of claims processing systems (EZCAP preferred).
• Working knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
• Understanding of different payment methodology such as Medicare PPS (MS-DRG, APC, etc.), Medicare Physicians fee schedule, Per Diem, etc.,
• Understanding of Division of Financial Responsibility on how they apply to claims processing
• Familiarity with billing and coding edits, coordination of benefits, MA Organization, Determination, Appeals and Grievance procedures
• Proven problem-solving skills and ability to translate knowledge to the department.
• Working knowledge of Microsoft Office Programs (Outlook, Excel and Word)
• Excellent verbal and written communication skills.
• Strong Organizational Skill and ability to multitask
• Attention to Detail.
• Ability to use 10 keys.

None.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.