Provider Dispute Resolution Analyst- Hybrid Remote

2 weeks ago

Alameda, United States VetJobs Full time

Job Description

ATTENTION MILITARY AFFILIATED JOB SEEKERS

- Our organization works with partner companies to source qualified talent for their open roles. The following position is available to

Veterans, Transitioning Military, National Guard and Reserve Members, and Military Spouses . If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps. This position is Hybrid and must be in the Alameda County area . Under the general direction of the Supervisor, Provider Dispute Resolution Supervisor the Provider Dispute Resolution (PDR) Analyst will review, research, and resolve complex and involved provider disputes for contracted as well as non-contracted providers in accordance with state and federal guidelines. Conduct all pertinent research in order to evaluate, respond and close incoming Provider Disputes accurately, timely and in accordance with all established regulatory guidelines. The PDR Analyst will process/adjust the disputed claim(s) accordingly while following department processes, interfacing with internal departments and external resources, as needed.

Principal responsibilities include:

Conduct investigation, review and resolve provider disputes accurately, timely and according to regulatory requirements. Maintain, track and prioritize assigned caseload through the provider dispute application to ensure timely completion and adherence to regulatory guidelines. Review provider disputes and provide a detailed analysis of findings in the PDR application. Research and analyze provider issues to determine the root cause of the dispute. Research and evaluate contract terms; interpret and compile necessary supporting documentation for the resolution of a provider disputed claim. Process/adjudicate and notate the claim accordingly within the Provider Dispute application adhering to department processes. Review and process complex disputes requiring a more in-depth understanding of appropriate payment methodologies or denial practices, benefits, policies and procedures, and contract interpretation. Send written responses to providers in a professional manner, free of grammatical errors within required regulatory timelines. Respond to provider inquiries regarding disputes that have been submitted. Maintain knowledge of claims procedures and all appropriate reference materials, participate in ongoing training as needed. Properly distinguish between a provider dispute and a provider appeal and generate and/or escalate a provider appeal for payment as appropriate and according to regulatory guidelines Assist in the preparation for all internal, external and regulatory audits Communicate with a variety of people, both verbally and in writing, to perform research and gather information related to the case that is under review. Identify and document opportunities for provider education. Document all provider inquires including phone calls, email, or written correspondence via the PDR application. Participate in standing meetings as necessary, including but not limited to, provider relations, contracting, network development and team building. Provide expertise and assistance relative to provider billing and payment guidelines consistent with AAH policies and procedures in conjunction with State and Federal guidelines. Keep current with all policies, procedures and regulatory guidelines to effectively interpret requirements as related to provider disputes. Sign into the Cisco phone system and answer provider calls as assigned through the phone system. Assist with special projects, as needed. Perform other duties as assigned. ESSENTIAL FUNCTIONS OF THE JOB

Ensure all received PDRs are processed and resolved within regulatory guidelines. Review, research and uphold/overturn disputed claims, as appropriate. Keep current with all policies, procedures and regulatory guidelines to effectively interpret requirements as related to disputes. Participate in meetings to discuss ongoing trends and issues regarding the most frequently received PDRs. Maintain the strict confidentiality required for medical records and other data such as PHI. Perform ongoing data entry within the PDR application. Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Salary : $33.46 - $50.20/hr

Certificates/Security Clearances/Other

High School Diploma or equivalent is required. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Minimum of 2-3 years of experience in a managed care claims processing environment required, including the processing of all medical claim types and the handling of complicated claims issues. Minimum 1-2 years of progressive experience as a PDR Coordinator preferred. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Knowledge of claims processing systems Knowledge of medical terminology, reference publications and standard coding including, but not limited to, CPT, HCPCS, revenue codes, ICD-10, DRG, RBRVS, etc. Proven problem-solving skills and ability to translate knowledge to the department Excellent verbal and written communication skills Ability to multi-task, strong organizational skills and attention to detail Familiarity with state and federal regulatory requirements Ability to read and interpret provider contracts and apply written guidelines and instructions Ability to correctly interpret claims processing rules, regulations and procedures Knowledge of HealthSuite preferred

Additional Qualifications/Responsibilities

Constant and close visual work at desk or computer Constant sitting and working at desk Constant data entry using keyboard and/or mouse Frequent use of telephone headset Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person Frequent lifting of folders and other objects weighing between 0 and 30 lbs Frequent walking and standing Number of Employees Supervised: 0 #J-18808-Ljbffr

  • Provider Dispute Resolution Analyst

    2 weeks ago

    Alameda, United States Alamedaalliance Full time

    Brief Description PRINCIPAL RESPONSIBILITIES : Under the general direction of the Supervisor, Provider Dispute Resolution Supervisor the Provider Dispute Resolution (PDR) Analyst will review, research, and resolve complex and involved provider disputes for contracted as well as non-contracted providers in accordance with state and federal guidelines. Conduct...

  • Provider Dispute Resolution Analyst

    2 weeks ago

    Alameda, United States Alameda Alliance Full time

    PRINCIPAL RESPONSIBILITIES : Under the general direction of the Supervisor, Provider Dispute Resolution Supervisor the Provider Dispute Resolution (PDR) Analyst will review, research, and resolve complex and involved provider disputes for contracted as well as non-contracted providers in accordance with state and federal guidelines. Conduct all pertinent...

  • Business Process Analyst

    1 week ago

    Alameda, United States INTELLECTT INC Full time

    Role:Business Process Analyst Location :Remote Responsibilities Collaborate with Business Process Manager to transform listed activities from supplteams and IT professionals into visual flows in a business process managementtool. Participate in interviews, workshops, and process discussions to capture the nuances and intricacies of each step within the...

  • Compensation Analyst

    5 days ago

    Alameda, United States Kairos Power Full time

    Job Summary Kairos Power is seeking a highly motivated and detail-oriented Compensation Analyst that will be responsible for designing, implementing, and evaluating Kairos Power’s compensation programs. The role will report to the Manager of Compensation and Equity and work closely with People Operations, Finance and other teams. This is a highly...

  • Sales Enablement Analyst

    2 weeks ago

    Alameda, United States International Search Consultants Full time

    Job Description Job Description Sales Enablement Analyst Remote Ready to transform sales effectiveness through data-driven insights? ISCs Executive Recruiters have been retained by a leading energy management company on a Sales Enablement Analyst opportunity. This exciting role is pivotal in shaping sales strategy and empowering the team to achieve...

  • Associate Governmental Program Analyst

    1 week ago

    Alameda County, CA, United States Department of Transportation Full time

    Under the supervision of the Procurement and Property Management Branch, a Staff Services Manager I, the incumbent is responsible for providing purchasing services to District 4 District Director, Chief Deputy, Chief of Staff and Administrative and staff. The incumbent is responsible to monitor and analyze available administrative (allocated and negotiated)...

  • Member Services Representative I

    1 month ago

    Alameda, United States ALAMEDA ALLIANCE FOR HEALTH Full time

    **PRINCIPAL RESPONSIBILITIES**: Member Services Representatives are under the direction of a Member Services Supervisor, Manager and Director, and service our members through our call center as well assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of...

  • Business Process Analyst

    2 weeks ago

    Alameda, United States ALAMEDA ALLIANCE FOR HEALTH Full time

    **PRINCIPAL RESPONSIBILITIES**: Under the general supervision of the Senior Manager, Project Management Office (PMO), the Business Process Analyst (BPA) is responsible for partnering across the organization to analyze processes to identify, document and drive change. Key initiatives include Enterprise level projects and the Medicare Readiness program, which...

  • Management Analyst

    3 days ago

    Alameda, United States Housing Authority Of The City Of Alameda Full time

    MANAGEMENT ANALYST AHA is expanding its housing services and as a result is seeking several exceptional, team-oriented candidates to work at the Management Analyst level. Management Analysts work on a wide range of analytical, management, and technical assignments supporting AHA operations and programs, and will have the opportunity to perform meaningful and...

  • Lead Certification Analyst

    6 days ago

    Alameda, United States Transdev Inc. Full time

    Lead Certification AnalystJob Description Division:                Paratransit Location:               San Francisco, CA Position:                Lead Certification Analyst Reports to:            Manager of Eligibility Programs Position Type:        Full-time, Regular, Hourly (Non-exempt) Salary...

  • IT Support Engineer, Level-II

    3 days ago

    Alameda, United States GSPANN Technologies, Inc Full time

    About GSPANNHeadquartered in Milpitas, California (U.S.A.), GSPANN provides consulting and IT services to global clients, ranging from mid-size to Fortune 500 companies. With our experience in retail, high technology, and manufacturing, we help our clients transform and deliver business value by optimizing their IT capabilities, practices, and operations....

  • DeskSide Support Engineer, Level 2

    1 day ago

    Alameda, United States GSPANN Technologies, Inc Full time

    About GSPANNHeadquartered in Milpitas, California (U.S.A.), GSPANN provides consulting and IT services to global clients, ranging from mid-size to Fortune 500 companies. With our experience in retail, high technology, and manufacturing, we help our clients transform and deliver business value by optimizing their IT capabilities, practices, and operations....

  • Electronic Data Interchange

    1 week ago

    Alameda, United States Penumbra Full time

    The Electronic Data Interchange (EDI) Analyst will be responsible for managing Penumbra’s EDI system and transactions. It is a critical position to ensure the success of EDI usage and will be the primary point of contact between Penumbra and customers to resolve EDI issues. **What You’ll Work On** - Monitor, troubleshoot, and resolve EDI issues and...

  • Member Services Representative I

    23 hours ago

    Alameda, United States Alameda Alliance Full time

    PRINCIPAL RESPONSIBILITIES: Member Services Representatives (MSR) are the first point of contact for our members' primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls in a...

  • Member Services Representative I

    6 days ago

    Alameda, United States Alameda Alliance for Health Full time

    DescriptionPRINCIPAL RESPONSIBILITIES: Member Services Representatives (MSR) are the first point of contact for our members' primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls...

  • Cancer Information Specialist

    6 days ago

    Alameda, United States AMERICAN CANCER SOCIETY Full time

    The people who work at the American Cancer Society focus their diverse talents on our lifesaving mission. It is a calling. And the people who answer it are fulfilled. **This is a full time permanent remote opportunity which can be home-based anywhere in California, Oregon or Washington State.** Start Date: June 3rd, 2024. Various schedules available...

  • Lead Engineer, Remote Handling

    6 days ago

    Alameda, United States Kairos Power Full time

    Job Summary Kairos Power is seeking a highly motivated Lead Engineer focused on Remote Handling with expertise in the development of mechanical and electromechanical remotely operated systems. In this role, you will design, demonstrate, and iteratively develop systems enabling in-cell reactor component maintenance and inspection with minimal impact to plant...

  • Staff Services Analyst

    5 days ago

    Alameda County, CA, United States State Coastal Conservancy Full time

    Love the North Coast, the San Francisco Bay Area, and the environment? This might be the job for you! - The State Coastal Conservancy has two exciting opportunities for you to join us in protecting California’s iconic lands and waters, restoring vital habitats, and increasing inclusive and equitable enjoyment of the coast and shoreline. **These positions...

  • Regulatory Compliance Specialist

    3 weeks ago

    Alameda, United States A-Line Staffing Solutions Full time

    A-Line Staffing Solutions is Hiring a Regulatory Compliance Specialist for a Managed Care Client in the Easy Bay - HYBRID - After training, the goal is for the position to be onsite 1 day per week, and 4 days per week remote Summary Under the directi Compliance Specialist, Regulatory, Compliance, Specialist, Healthcare, Staffing

  • Staff Services Analyst

    2 weeks ago

    Alameda County, CA, United States Department of Rehabilitation Full time

    This Job is located in the City of **OAKLAND**. Under the supervision of the Staff Services Manager I/Team Manager in the Vocational Rehabilitation Employment Division, the Staff Services Analyst (functional job title of Work Incentives Planner) performs a variety of analytical duties related to benefits and work incentives planning for Department of...