Job Function:
Onsite - Must be fully vaccinated. Must be able to work Monday through Friday 8am-5pm
Pay Rate: USD $29.22 – $36.52 / hr
What are the 3-4 non-negotiable requirements of this position?
Experience processing PDR documents.
Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.
The Provider Dispute Resolution Claims Examiner II is responsible for:
The accurate analysis and resolution determination of Provider Disputes from all sources.
Assist in the resolution of eligibility, benefit, contracting, and payment schedule issues.
Handle and document resolution to escalated telephone and written appeals.
Ensuring all PDR documents are processed timely with timely submission of all acknowledgement and resolution letters
Timely processing of complex PDR claims for all lines of business
Auditing claims for excessive charges, duplicates, unbundling, and medical up coding
Maintaining department databases used for report production and tracking on-going work
Assisting management with in-house and on-site training as offered to employees and providers.
Associate's Degree
At least 0-2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes.
Skills
Ability to operate PC-based software programs or automated database management systems. Strong communication skills with excellent analytical and problem- solving skills. Ability to self-manage in a fast-paced, detail-oriented environment. Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials(PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge. Moderate knowledge of Microsoft Word and Excel. Persuasion Skills: Persuading co-workers and management to accept recommendations for work flow or procedural changes to support process improvement efforts. In cases of provider payment dispute, Convincing the provider that their claims have been handled properly bases on the provider contract or regulatory guidelines.
|