Provider Dispute Resolution Specialist

TITLE

Provider Dispute Resolution Specialist

POSITION SUMMARY

The Provider Dispute Resolution (PDR) Specialist is responsible for overseeing and processing provider disputes accurately and timely, according to CMS guidelines. The supervisor assesses and completes appropriate documentation for tracking and trending data. The supervisor is also responsible for any reviewing and reporting any documentation for health plan auditing.

RESPONSIBILITIES-DUTIES

· Triage incoming appeals and properly distinguish between PDRs and appeals, then distribute to the correct department.

· Use internal tracking mechanisms to ensure proper processing timelines and the appropriate actions that need to be taken.

· Review and process PDRs according to CMS guidelines.

- Create proper acknowledgement letters

- Send to appropriate departments for additional information as needed

- Reprocess claims as needed for overturned PDRs

- Create proper resolution letters to close PDRs timely

· Assist in preparing and reviewing PDRs for health plan audits

· Assist in training of other members of the PDR team as needed

· Work with other departments as needed to make determinations on PDRs

EDUCATION & EXPERIENCE REQUIREMENTS

· 3 years experience processing and examining claims and PDRs

· Experience with EZCAP software a plus

· Understand different payment methodology and financial responsibility contracts/DOFRs

· Problem solving skills

· Analyze claims issues and communicating any changes needed with other AMM departments

· Expert analytical skills

· Ability to plan and organize things effectively

· Excellent communication skills, both verbal as well as writtenPrimary Responsibilities

• Develop and Support a paperless (electronic) system for conducting business
• Manage inbound data feeds including: all claim file types, MOR, MMR, DXHCC, RAPS, Reconciliation files, eligibility and capitation data
• Manage outbound encounter data submission and process, Alternate Submission Methods (ASM), and supplemental “Clinical” data submissions to health plan trading partners or designated clearinghouses.
• Responsible for full reconciliation of encounter data between AMM’s clients, Health plans and CMS
• Responsible to analysis Care gap reports to identify data gaps.
• Support the centralization of information for using Onbase for content management
• Support claims inload processes and procedures
• Lead all Encounter and EDI related projects
• Attend various meeting including: Operations, project specific, JOCs / encounter performance and adhoc.
• Communicate business needs, requirements and enhancement ideas
• Report issues and failures.
• Confirm audit and/or exception reports are run at appropriate frequencies and identified items and exceptions are resolved satisfactorily and within expected time frames.
• Work with AMM team to enhance operations, comply with new regulations, resolve failures and document policies and procedures

Required Skills and Abilities

• Bachelor's Degree (four-year college or technical school) Required, Field of Study: Computer Science, Information Systems or equivalent experience
• 3 years of experience in Software Development.
• Thorough knowledge of programming languages including VB, C#, SQL, PowerShell
• 3 years of SQL Server ETL Development experience using SSIS
• 3 years of experience with Microsoft SQL Reporting Services (SSRS)
• Proficient in using Team Foundation Server for source control
• Experience with SQL Server 2012
• Experience with Transactional Systems, specifically X12 Claims, Eligibility and Authorization transactions.
• EZCAP and EZEDI experience preferred.
• Experience with encounter data submission preferred
• Project management skills in the context of software development preferred
• Previous experience in the healthcare or finance industry preferred

Company InsightsAdvanced Medical Management, Inc. (AMM) provides operational, administrative and technical healthcare management services to large physician organizations, government agencies, and health plans. AMM's clients include approximately 2,000 physicians and 75,000 patients in various Independent Physician Associations (IPA). AMM processes more than $100 million annually in healthcare claims and other medical reimbursements. AMM's clients are located all throughout the State of California. AMM is a 36-year-old privately owned company located in beautiful Long Beach, California and currently occupies 18,000 square feet of prime office space adjacent to the Long Beach Airport.

Our mission at AMM is to offer flexible administrative healthcare services that improves patient health, obtains profitability, maintains independence and achieves 5-Star Quality. It is our goal to leave behind a legacy of trusted patient care with integrity. We proudly stand behind our core values and are committed to Quality, Integrity, and Collaboration.

We are looking for a dynamic candidate to join our company whom has excellent work ethic, a desire to contribute to company culture and innovation. This individual must also obtain the drive to succeed and flourish within our organization. The majority of our supervisory and management team have been promoted from within and it is our goal to continue the professional growth of every team member. This is an excellent opportunity for someone seeking a career transition with massive growth potential in the health care industry.

More Good Reasons!

• 100% Employer paid employee medical coverage through Kaiser or Health Net
• Employer paid life Insurance
• Vacation time!
• Nine paid holidays!
• Profit sharing (at company discretion)
• 100% Company matching of employee 401K contributions, up to 1% of annual salary
• Monthly birthday celebrations where we bring in lunch!

Job Type: Full-time

Pay: $23.00 - $27.00 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person

Salary : $23 - $27