Clinical Dispute Resolution Expert

4 days ago


Long Beach, California, United States Advanced Medical Manage Full time
Job Title: Clinical Dispute Resolution Expert

Job Summary:
We are seeking a highly skilled Clinical Dispute Resolution Expert to join our team at Advanced Medical Manage. As a key member of our organization, you will be responsible for managing and resolving disputes between our company and healthcare providers regarding reimbursement, claims processing, and contractual agreements.

Key Responsibilities:
  • Triage incoming appeals and properly distinguish between PDRs and appeals, analyze provider disputes regarding reimbursement, claims, or contractual agreements and transfer issues to the correct departments.
  • 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 and 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.

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 and expert analytical skills.
  • Ability to plan and organize things effectively.
  • Excellent communication skills, both verbal as well as written.

Salary:$60,000 - $80,000 per year.

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