Provider Dispute Resolution Lead

Job Number: 2835

Workplace Type:

Position Title: Provider Dispute Resolution Lead

External Description:

Position Summary:

The Provider Dispute Resolution Lead (“Lead”) will assist the management in the day to day operations of Provider Dispute and Appeals unit within Claims Department. The Lead shall serve as the subject matter expert for all related provider disputes and provider appeals and support to Management. The Lead will conduct audits and trainings as assigned.

General Duties/Responsibilities:

(May include but are not limited to)

• Assist in monitoring claims inventory and work loads which include but not limited to Provider disputes and appeals assignment, special projects such as Out of Pocket payment adjustments, member services inquiry and requests.
• Serve as subject matter expert for all related provider dispute and provider appeals reviews.
• Conducts audits and trainings as assigned.
• Process provider disputes and provider appeals according to CMS, contractual and departmental guidelines.
• Respond to inquiries from providers or other departments on PDR related issues via phone, email or in person.
• Work on escalated issues from PDR Analyst that required extensive research and resolution.
• Correspond with delegated entity as needed to obtain appropriate records or payment information. Follow through and ensure requested information are obtained.
• Produce written correspondence to resolve provider appeals and disputes. Ensure communications contain rationale which supports the determination or resolution of provider appeals or provider disputes.
• Prepare 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.
• Meets and consistently maintains quality and productivity standards as defined by the Management.
• Update and review tracking system to ensure cases are processed timely and appropriate actions are taken.
• Identify opportunities for improvement in the PDR function and propose solutions.
• Run and monitor various reports which include but not limited to CMS required reporting (Part C, ODAG reports for reconsideration and dismissals, etc.) and other departmental reports.
• Provides documentations as requested by other departments such as Compliance and Member Appeals and Grievance.
• Collaborates with other departments and outsourcing vendor for the resolutions of provider disputes and provider appeals.
• Participate in CMS and other health plan audits related to provider dispute and provider appeals.
• Identifies root causes of claims denial or payment variance and escalates to department management as appropriate for training opportunities and corrective action.
• Assists in preparing and reviewing cases for regulatory and other health plan audits.
• Actively participates in ongoing training to support company and department initiatives.
• Supports department initiatives in improving processes and workflow efficiencies.
• Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.
• Complies with company’s time and attendance policy.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
• Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.
• Performs additional related duties as assigned.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Provider Dispute Resolution Lead

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].