Provider Dispute Resolution Specialist I, South San Francisco, CA
Provider Dispute Resolution Specialist I
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a Provider Dispute Resolution Specialist I to review and resolve provider disputes for all lines of business for contracted as well as non-contracted providers in accordance with state and federal statutes, regulations, and program guidance.
The essential duties and responsibilities will include the following:
- Review and process provider dispute resolutions according to state and federally defined timeframes.
- Research issues; adjust claims and determine the root cause of the dispute.
- Send written responses to providers in a professional manner within required timelines.
- Review and price a variety of claims edits related to most claim types to determine the appropriate handling for each including payment or denial.
- Complete the required number of weekly reviews deemed appropriate for this position.
- Answer provider inquiries regarding disputes that have been submitted.
- Maintain, track and prioritize assigned caseload through HPSM’s provider dispute database to ensure timely completion.
- Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed.
- Monitor own performance via production and auditing tools and reports.
- Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review.
- Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
- Attend team, company and one-on-one meetings and other functions.
- Communicate issues with Supervisor and Compliance Auditor as required.
- Perform other duties as assigned.
Education and Experience: High school diploma, GED or equivalent required. Three (3) years of work as a Claims Provider Services Representative, Claims Examiner or Provider Dispute Resolution Specialist in a health services or managed care setting.
Knowledge of: Medi-Cal and Medicare programs. Medical claims processing procedures. Medical terminology and standard claim forms. CPT, HCPCS, revenue and ICD-9 coding. Benefit interpretation and administration. AB-1455 regulations. General personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint.
Ability to: Work in a fast-paced, highly pressured, and changing environment. Be resourceful and use initiative to resolve problems/issues. Communicate effectively with others, both verbally and in writing. Establish and maintain cooperative working relationships with a variety of people. Accurately perform highly detailed work. Organize/prioritize tasks. Prepare basic reports.
Starting Compensation Range: Depends on Experience.
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: email@example.com or via fax: (650) 616-8039. File by: Continuous until filled. EOE
Submissions without a Cover Letter and salary expectations may not be considered.