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Appeals and Grievances, Intermediate
2 weeks ago
Your Role
The Provider Dispute Resolution Team is looking for an Intermediate Provider Dispute Resolution Coordinator that can research, review and resolve high level/high priority provider grievances, appeals and complaints, while clarifying issues and educating providers in the process. The Intermediate Provider Dispute Coordinator will report to the Commercial Supervisor. In this role, the coordinator should be able to make independent decisions and appeal determinations. The candidate should effectively manage their time and prioritize their workload to ensure compliance timeframes and project deadlines are met.
Your Knowledge and Experience
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Requires a high school diploma or GED
Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination.
Requires previous appeal and or dispute experience
Requires claims processing, including adjustments, interest accuracy proficiency, general suspense and back-end claims experience.
Strongly preferred experience in Commercial LOB claims and/or appeals
Preferred experience in Medi-Cal and/or Medicare LOB claims and/or appeals
Preferred knowledge of applicable legislation/regulations and compliance.
Preferred knowledge of following systems - Facets, DocDNA, Smartcomm, Documentum, CLMS, CMS Pricers = 3M Pricer, DRG Pricer, SNF Pricer, CareWebQI.
Strong skill set of Microsoft Office applications
Demonstrated experience with free format letter writing
