Claims Dispute Analyst

Community Health Group; Chula Vista (CA); In loco; USD 52.000 - 76.000; Tempo pieno

Descrizione del lavoro

Community Health Group seeks an Administrative Support Worker to investigate and resolve provider claim appeals and adjustments. You will assess documentation, apply contractual terms and regulatory guidelines, and document findings in the Provider Dispute Module and QNXT.

This role supports multiple product lines and requires attention to detail and clear communication. Minimum five years in dispute resolution and claims adjudication, with knowledge of AB1455 regulations, CPT/ICD10 coding, and

Competenze

• High school diploma or equivalent; bachelor’s degree preferred.
• At least five years experience in dispute resolution and claims adjudication.
• Strong knowledge of AB1455 regulatory requirements.
• Knowledge of CPT and ICD10 coding and medical terminology.
• Knowledge of claims dispute determination and resolution procedures and coding practices.
• Ability to read, analyze and interpret regulations and contract language.
• Excellent customer service and writing skills.
• Good judgment, problem solving, and ability to work independently.
• Team player and able to work with multiple departments.

Mansioni

• Investigates and resolves provider claim appeals and requests for adjustment for all product lines by evaluating documentation and determining compliance with provider contracts or reimbursement guidelines.
• Adheres to regulatory requirements and internal policies; interprets policies from Claims, Health Care Services, and Member Services.
• Documents relevant facts in Provider Dispute Module and QNXT; presents recommendations after thorough review.
• Maintains professional image and participates in teams and meetings; performs other duties as assigned.

Conoscenze

Dispute resolution

Claims adjudication

Regulatory knowledge

AB1455 knowledge

CPT/ICD10 coding

Medical terminology

Customer service

Technical writing

Problem solving

Team player

Independent work

Formazione

High school diploma

Bachelor’s degree preferred

Strumenti

Provider Dispute Module

QNXT

Descrizione del lavoro

EEO-1: Administrative Support WorkerPOSITION SUMMARYEnsures compliance with regulatory requirements for provider dispute matters by investigating and resolving a range of provider claim appeals and requests for adjustments. Addresses provider disputes, based on CHGs protocols and regulatory requirements.COMPLIANCE WITH REGULATIONSWorks closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and Medi-Cal.RESPONSIBILITIESInvestigates and resolves provider claim appeals and requests for adjustment for all product lines by evaluating documentation provided by the appellant, identifying if initial claim was paid in accordance with terms and conditions of provider contract or established reimbursement guidelines, adhering to contractual requirements established by regulatory agencies, interpreting policies and procedures from other internal departments (Claims, Health Care services, and Member Services), meeting all requirements specified on Provider Dispute Resolution policy and procedure, making claim appeal determination (payment, reduction, or denial) based on circumstances identified through case research and investigation, and documenting relevant facts related to the case on the internal Provider Dispute Module and QNXT.Conducts thorough the review of provider disputes in presenting recommendations.Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.EDUCATIONHigh school diploma or equivalent training.Bachelors Degree preferred.EXPERIENCE/SKILLSFive years of experience involving dispute resolution and claims adjudication.Strong knowledge of AB1455 regulatory requirementsKnowledge of CPT and ICD10 coding, and medical terminology.Knowledge of claims dispute determination and resolution procedures and coding practices.Ability to read, analyze and interpret regulations and contract language.Excellent customer service skills.Good technical writing skills.Good judgment and problem solving skills; team player; and ability to work independently.PHYSICAL REQUIREMENTSProlonged periods of sitting and frequent walking.May be required to work evenings and weekends.The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.