Provider Dispute Specialist

Blue Cross and Blue Shield of Louisiana Inc.; Baton Rouge (LA); On-site; USD 55,000 - 75,000; Full time

Job summary

Blue Cross and Blue Shield of Louisiana seeks a Provider Disputes Coordinator to ensure accurate classification and processing of disputes for HMOLA and BCBSLA. Residency in Louisiana is preferred; reporting to the Monroe or Baton Rouge office.

You will coordinate responses, review calls and documentation, and ensure compliance with accreditation guidelines and state laws. Strong attention to detail and excellent communication are essential.

Qualifications

• High school diploma or equivalent required.
• 4 years health insurance experience required; 2 years in customer service or provider relations preferred.
• Ability to read and interpret benefits across lines of business.
• Thorough knowledge of claims process and adjustment procedures.
• Knowledge of accreditation guidelines, state laws, and internal claims systems.
• Working knowledge of PC software; Facets experience required.
• Strong attention to detail, record-keeping, and communication skills.
• Able to work in a fast-paced, changing environment; presentations/public speaking skills required.

Responsibilities

• Coordinate response activities between appropriate departments, reviewing calls and related documentation to verify pricing and analyze errors.
• Send written resolution letters within required timeframes for provider disputes.
• Provide acknowledgement letters to notify receipt and timelines for dispute resolution.
• Coordinate and host Management Level Provider Dispute meetings with internal and external parties, prepare packets, and take minutes.
• Facilitate meetings to ensure all viewpoints are heard and addressed.
• Coordinate audits and adjustments for systemic issues and provide on-site or telephonic education on contract concerns.
• Back up for Appeals and Grievance Analysts and other team duties as needed.
• Close inventory with accuracy to address all concerns.

Skills

Benefits interpretation

Claims processing

Accreditation guidelines

State laws

Claims systems

Facets experience

Attention to detail

Record keeping

Communication skills

Public speaking

Education

High School Diploma or equivalent

Tools

Facets

Job description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities.

Residency in or relocation to Louisiana is preferred for all positions. This position will require reporting to the Monroe or Baton Rouge office.

Position Purpose

Ensures the accurate and timely classification and processing of all provider disputes received for HMOLA and BCBSLA.

Ensures the units compliance with accreditation guidelines pertaining to provider disputes.

Coordinates responses to provider disputes by sending a formal letter.

Complies with all laws and regulations associated with duties and responsibilities.

Nature and Scope

This role does not manage people.

This role reports to this job: SUPERVISOR, PROVIDER DISPUTES.

Qualifications

• Education: High School Diploma or equivalent is required.


• Work Experience: 4 years of health insurance experience is required. 2 years of experience in a customer service or provider relations environment is preferred.


• Skills and Abilities: Must be able to read and interpret benefits for all lines of business. Must have a thorough knowledge of the claims process and adjustment procedures. Detailed knowledge of accreditation guidelines, state laws, and internal claims systems is necessary. Working knowledge of relevant PC software and applicable systems is necessary. Facets experience is required. Requires attention to detail, and strong record-keeping skills. Must demonstrate ability to work in a rapidly paced and ever-changing environment. Strong grammar, spelling, verbal and written communication skills are necessary. Presentation and public speaking skills are required.


• Licenses and Certifications: None required.

Accountabilities and Essential Functions

Coordinates response activities between appropriate departments, conducts necessary investigation by reviewing telecommunication tapes of related and pertinent calls, as well as any documentation or claims submitted by members or providers in order to verify correct pricing and analyze claim inquiry data to determine root cause of errors to ensure contracts and reimbursement policies and procedures are priced accurately.

Sends written resolution letters to appropriate parties within the required time frame for all network provider disputes in accordance with all appropriate Healthcare Accreditation entities.

Gives acknowledgement letters on all provider disputes within the required timeframe to notify the requester that we have received their request and to advise him/her of the timeframe in which the appeal will be resolved.

Coordinates and hosts Management Level Provider Dispute meetings between internal management from various areas within the Plan and the provider or his/her representative. This includes contacting providers and relevant internal management, preparing dispute packets, and taking minutes during the meeting.

Must be able to facilitate the meetings in such a way that all appropriate audience views are heard and addressed as necessary.

Coordinates various tasks including but not limited to audits and adjustments for identified systemic problems with programming and providing onsite or telephonic education on contract related concerns in order to maintain compliance with Healthcare Accreditation entities.

Handles other assignments, including but not limited to working the Imaging Auto Work Distribution and serving as back up to the Appeals and Grievance Analysts, to help the department reach goals and maintain compliance.

Closes assigned inventory with accuracy and detail in order to address all concerns thoroughly.

Closes assigned inventory with accuracy and detail in order to address all concerns thoroughly.

Performs other related duties as needed, including but not limited to, back up support for other employees.

Complies with all laws and regulations associated with duties and responsibilities.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.

Perform other job-related duties as assigned, within your scope of responsibilities.

Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer.

Company Mission

In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being.

Health and Safety Policies

• Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.


• We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus.


• Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.


• We are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

Company Vision and Identity

Company Vision: A better state of health through preventative, easier and more affordable healthcare.

Blue Cross and Blue Shield of Louisiana (Louisiana Blue) is incorporated as Louisiana Health Service & Indemnity company and is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross and Blue Shield of Louisiana is licensed to sell products only in the state of Louisiana.