Provider Claims Dispute Specialist

Community Health Group; Chula Vista (CA); On-site; USD 52,000 - 76,000; Full time

Job summary

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

Qualifications

• 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.

Responsibilities

• 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.

Skills

Dispute resolution

Claims adjudication

Regulatory knowledge

AB1455 knowledge

CPT/ICD10 coding

Medical terminology

Customer service

Technical writing

Problem solving

Team player

Independent work

Education

High school diploma

Bachelor’s degree preferred

Tools

Provider Dispute Module

QNXT

Job description

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