Provider Dispute and Resolution Analyst II

L.A. Care Health Plan; Los Angeles (CA); On-site; USD 67,000 - 107,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan is hiring two Provider Dispute and Resolution Analysts II to investigate, analyze, and resolve provider claims and payment disputes for contracted network providers in a timely and accurate manner.

These roles require strong analytical abilities, meticulous documentation, and collaboration with Claims, Configuration, and Finance teams to ensure fair outcomes and alignment with contractual payment terms.

Qualifications

• At least 2 years of experience researching, analyzing, coordinating, and resolving provider claims and payment disputes in a healthcare or managed care setting.
• Experience reviewing provider claims, payment information, and supporting documentation to determine the appropriate resolution pathway.
• Ability to work within policies and escalation protocols and collaborate with Claims, Configuration, Finance, and provider contract representatives.

Responsibilities

• Research and resolve routine to moderately complex provider claims and reimbursement disputes.
• Coordinate with stakeholders to validate disputes against contractual rates and payment mechanisms.
• Maintain accurate case records and communicate findings and resolution status to providers.
• Escalate high-risk or ambiguous matters to leadership for strategic oversight.
• Support provider settlement activities including documentation and tracking of progress.

Skills

Analytical skills

Record-keeping

Cross-functional collaboration

Communication skills

Education

Associate's Degree

Job description

Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

(2 positions available)

The Provider Dispute and Resolution Analyst II is responsible for researching, analyzing, coordinating, and resolving routine to moderately complex provider claims, payment disputes, and reimbursement issues for contracted network providers. This role serves as part of a dedicated provider resolution function designed to improve the timeliness and consistency of provider payment issue resolution. The Analyst II reviews provider claims, payment information, applicable contract terms, configuration, and supporting documentation to determine the appropriate resolution pathway. Working within established policies, workflows, reimbursement guidance, and escalation protocols, the Analyst II partners stakeholders to resolve provider concerns and coordinate corrective claim action when necessary. The Analyst II provides analytical and administrative support for non-litigation provider settlement activities including claim research, payment validation, reconciliation, and tracking of approved resolution activity. This role independently resolves routine and moderately complex matters while escalating higher-risk, systemic, financially significant, or contractually ambiguous disputes to appropriate leadership.

Duties

Safeguards the organization’s financial and reputational interests by expertly managing provider claims and reimbursement disputes. Reviews and resolves routine to moderately complex cases, requiring thorough research of claim histories and provider documentation to ensure fair and accurate outcomes. Partners with key stakeholders to validate disputes against contractual rates and payment mechanisms, documenting remediation activities with precision. Maintains meticulous case records and fostering timely, transparent communication with providers. Escalates disputes that surpass established complexity or financial thresholds, ensuring that senior leadership is engaged when strategic oversight is required. Delivers analytical support for provider settlement reviews by researching claims and payment histories, reconciling disputed inventories, preparing documentation for settlement evaluation, and tracking approved activities. Promptly escalates discrepancies or unresolved items, reinforcing accountability and organizational transparency. Establishes dispute resolution policies and frameworks, preparing clear, provider-facing responses that communicate findings and resolution status The role demands objective, sensitive communication, especially in potentially challenging provider interactions. Champion continuous improvement, share best practices, and promote a culture of accountability, collaboration, and decision quality. Builds upon foundational competencies and cultivates leadership qualities that drive organizational progress. Ensures that the organization’s dispute resolution process is both robust and responsive by integrating analytical rigor, cross-functional collaboration, and proactive escalation Upholds contractual integrity, optimizing financial outcomes, and enhancing provider relationships. Performs other duties as assigned.

Duties Continued

Establishes dispute resolution policies and frameworks, preparing clear, provider-facing responses that communicate findings and resolution status The role demands objective, sensitive communication, especially in potentially challenging provider interactions. Champion continuous improvement, share best practices, and promote a culture of accountability, collaboration, and decision quality. Builds upon foundational competencies and cultivates leadership qualities that drive organizational progress. Ensures that the organization’s dispute resolution process is both robust and responsive by integrating analytical rigor, cross-functional collaboration, and proactive escalation Upholds contractual integrity, optimizing financial outcomes, and enhancing provider relationships. Performs other duties as assigned.

Education Required

Associate's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Experience

Required:

At least 2 years of experience in researching, analyzing, coordinating, and resolving provider claims, payment disputes, and reimbursement issues within a healthcare or managed care environment. Experience reviewing provider claims, payment information, contract terms, and supporting documentation to determine the appropriate resolution pathway. Experience working within established policies, workflows, reimbursement guidance, and escalation protocols is essential, as is partnering with Claims, Configuration, Finance, and provider contract representatives to resolve provider concerns and coordinate corrective claim action when necessary.

Preferred:

Experience preparing documentation for settlement evaluation.

Skills

Required:

Demonstrate strong analytical abilities to research and resolve provider claims and reimbursement disputes. Essential skills include meticulous record-keeping, effective cross-functional collaboration, and adherence to established dispute resolution policies. Communications skills with the ability to have a clear, objective communication with providers, timely escalation of complex cases, and a commitment to continuous improvement and accountability.

Preferred:

Advance analytical support for settlement reviews. Ability to elevate unresolved items to senior leadership, sharing best practices, and promoting decision quality will be highly valued. Leadership skills that foster collaboration and drive organizational progress are also desirable.

Physical Requirements

Light

Additional Information

Travel to offsite locations for work required.

Salary Range Disclaimer:

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care Offers a Wide Range Of Benefits Including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)