Provider Dispute Resolution Analyst

4 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 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.

PHYSICAL REQUIREMENTS

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

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

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

SALARY RANGE $33.46-$50.20 HOURLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.

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