Provider Dispute Resolution Coordinator
Location: Orange, California US
Job Number: 1244
Position Title: Provider Dispute Resolution Coordinator
The Provider Dispute Coordinator is the point of contact for submission/resolution of Provider Disputes and Appeals. The Coordinator assesses and completes appropriate documentation for tracking/trending data. Conducts all pertinent research to evaluate, respond and close incoming Provider Disputes accurately, timely and in accordance with all established regulatory guidelines. Interface with internal departments and external resources and organizations. Prepares and assist with reports for the claims department.
- Research & evaluate contract terms/interpretation and compiles necessary supporting documentation for the resolution of provider disputed claims.
- Responds to incoming Provider Disputes accurately, timely and in accordance with all established regulatory guidelines.
- Processes/Adjudicates and notates the claim(s) accordingly within the Claim system adhering to department processes.
- Research/Evaluate, respond and close incoming Provider Disputes and Appeals accurately, timely and in accordance with all established regulatory guidelines.
- Maintain tracking system of Provider Disputes/Appeals correspondence outcomes in accordance with claims processing guidelines set forth to reflect accurate information in a clear, concise, grammatically correct format.
- Updates tracking system of Provider Disputes & Appeals (as applicable) correspondence outcomes in accordance with claims processing guidelines set forth to reflect accurate information in a clear, concise, grammatically correct format.
- Identifies denial or payment variance trends and escalates to department management as appropriate for training opportunities and corrective action.
- Responsible for monthly reporting of Provider Disputes/Appeals resolution through reporting mechanism.
- Responsible for answering /resolving provider inquires accurately and thoroughly
- Ensure the privacy and security of PHI (Protected Health Information) as outlines in the department policies and procedures relating to HIPAA Compliance
- Performs other duties and projects as assigned.
- High School Diploma.
- 3+ Year’s experience in claims examining, processing and adjudicating institutional and professional claims.
- Knowledge of claims processing systems (EZCAP preferred).
- Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
- Proven problem solving skills and ability to translate knowledge to the department.
- Working knowledge of Microsoft Office Products.
- Background in Medicare Advantage and/or Medical Group/IPA claims preferred.
- Excellent verbal and written communication skills.
- Ability to multitask.
- Strong Organizational Skills.
- Attention to Detail.
- Ability to use 10 key.
- Familiarity with CMS regulatory requirements.
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.
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Basic computer knowledge.
- Other Skills and Abilities:
- Team player.
- Multi-tasking capabilities.
- Good written and verbal communication skills required.
- Ability to operate a telephone, computer, copier, fax machine, and other office
- 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.
- 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.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate
Location City: Orange
Location State: California
Community / Marketing Title: Provider Dispute Resolution Coordinator
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org.