Provider Dispute Resolution Specialist

LaSalle Medical Associates IPA; California (MO); On-site; USD 60,000 - 80,000; Full time

Job summary

LaSalle Medical Associates IPA is hiring a Provider Dispute Resolution Specialist in California. This role involves the timely review and resolution of provider disputes related to claims adjudication. Candidates should have at least 5 years of experience in managed care health claims and strong skills in medical coding. The position requires proficiency with claim forms and excellent communication skills, supporting compliance with relevant regulations while fostering positive relations with providers.

Qualifications

• 5+ years of experience processing managed care health claims.
• 2+ years in Provider Dispute Resolution or Appeals within Medicare or Medicaid environments.

Responsibilities

• Review and resolve provider disputes related to claims adjudication.
• Ensure compliance with state and federal regulations.
• Support positive provider relations.

Skills

Knowledge of managed care claims operations

Medical coding proficiency

Experience with claim forms (UB-04, CMS-1500)

Data analysis skills

Strong communication skills

Time management skills

Proficiency in Microsoft Office

Problem-solving skills

Education

High school diploma or equivalent

Coursework in healthcare administration or medical billing

Job description

JOB SUMMARY

The Provider Dispute Resolution Specialist is responsible for the accurate, timely, and compliant review and resolution of provider disputes and appeals related to claims adjudication, reimbursement, coding, and authorization determinations. This role ensures compliance with applicable California state and federal regulations, contractual obligations, and internal policies while supporting positive provider relations.

REQUIREMENTS

MINIMUM & PREFERRED QUALIFICATIONS

EDUCATION/TRAINING

• Minimum: High school diploma or equivalent.
• Preferred: Coursework or training in healthcare administration, medical billing, or related field.

EXPERIENCE

• Minimum: 5+ years of experience processing managed care health claims.
• Preferred: 2+ years of direct Provider Dispute Resolution and/or Appeals experience within Medicare, Medi-Cal/Medicaid, Commercial, PPO, and/or HMO environments.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

SKILLS, KNOWLEDGE & ABILITIES

• Strong working knowledge of managed care claims operations and regulatory requirements, including dispute and appeal timeliness standards.
• Proficiency with medical coding concepts (ICD-10, CPT, HCPCS, DRG, ASC).
• Experience with UB-04 and CMS-1500 claim forms.
• Ability to analyze complex data, identify discrepancies, and apply contract terms accurately.
• Strong written and verbal communication skills in English.
• Effective time management skills with the ability to manage competing priorities and workload volumes.
• Intermediate proficiency with Microsoft Office applications, including Word and Excel.
• Demonstrated problem-solving skills and attention to detail.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position primarily involves sedentary work with routine use of a computer and standard office equipment. The role may require occasional light physical activity (up to 10 pounds) and brief periods of bending, reaching, or filing. The employee must be able to maintain concentration for extended periods, analyze detailed information, and meet regulatory deadlines, with or without reasonable accommodation.