Provider Dispute Resolution Specialist

Ventura County Medi-Cal Managed Care Commission; California (MO); Ibrido; USD 44.000 - 62.000; Tempo pieno

Descrizione del lavoro

Gold Coast Health Plan is seeking a provider disputes analyst to investigate, analyze, and resolve disputes in line with regulatory requirements and organizational policies. You will research claims, payments, benefits, authorizations, and contracts to determine appropriate resolution, processing disputes accurately within set timeframes and documenting outcomes.

The role requires knowledge of Medi-Cal/Medicare, claims processing, and MS Office, with strong analytical and communication skills.

Competenze

• High school graduate or GED required.
• Knowledge of Medi-Cal, Medicare, and D-SNP programs and managed care operations.
• Familiarity with CPT, HCPCS, ICD-10-CM/PCS, UB-04/CMS-1500 claim forms and claims adjudication.
• Experience with COB, TPL, and standard claims processing practices.
• Knowledge of state and federal healthcare regulations for managed care.
• Provider contracting concepts and reimbursement methodologies.
• Proficient with claims processing systems and MS Office.

Mansioni

• Investigate, analyze, and resolve provider disputes per regulations and policies.
• Research claims, payments, benefits, authorizations, and contracts to determine dispute resolution.
• Process disputes within regulatory timeframes and document outcomes.
• Communicate status and decisions with providers and internal partners.
• Document findings and adjust claims in designated systems.

Conoscenze

Analytical skills

Research skills

Technical aptitude

Problem solving

Diversity oriented

Time management

Honesty / integrity

Communication (oral)

Communication (written)

Formazione

High school/GED

Driver's license & auto insurance

Strumenti

MS Office

Descrizione del lavoro

Gold Coast Health Plan is seeking a provider disputes analyst to investigate, analyze, and resolve disputes in line with regulatory requirements and organizational policies. You will research claims, payments, benefits, authorizations, and contracts to determine appropriate resolution, processing disputes accurately within set timeframes and documenting outcomes.

The role requires knowledge of Medi-Cal/Medicare, claims processing, and MS Office, with strong analytical and communication skills.