Provider Disputes Analyst - Drive Health Plan Solutions

Gold Coast Health Plan; Camarillo (CA); In loco; USD 67.000 - 93.000; Tempo pieno

Descrizione del lavoro

Gold Coast Health Plan is seeking a dedicated professional to manage provider disputes and ensure compliant, timely resolution. The role involves researching claims and contracts, coordinating with multiple departments, and maintaining accurate documentation.

Ideal candidates will have knowledge of Medi-Cal/Medicare, CMS guidelines, and strong communication skills. California residency is required for this position.

Competenze

• High School diploma or GED required.
• Knowledge of Medi-Cal, Medicare, and D-SNP programs and operations.
• Experience with medical billing, CPT/HCPCS/ICD-10 coding and claims processing.
• Familiarity with COB, TPL, and managed care business processes.
• Ability to communicate with providers and internal teams professionally.

Mansioni

• Investigate, analyze, and resolve provider disputes per regulatory and contractual requirements.
• Research claims, payment history, benefits, contracts, and documentation to determine disposition.
• Process disputes within regulatory timeframes and acknowledge/resolution requirements.
• Communicate dispute status and requests for additional information to providers and internal partners.
• Document findings, determinations, and adjustments in designated systems.
• Coordinate with Claims, Provider Relations, Utilization Management, Finance, IT, and other departments to resolve disputes promptly.
• Identify processing errors, payment discrepancies, or system issues and escalate as needed.
• Monitor inventory to ensure quality and productivity standards.
• Maintain knowledge of provider contracts, reimbursement methodologies, and relevant regulations.
• Participate in meetings, training, and quality improvement initiatives.

Conoscenze

Analytical skills

Research skills

Technical aptitude

Problem solving

Diversity oriented

Time management

Ethical

Judgment

Communication - oral

Communication - written

Honesty & integrity

Formazione

High School Diploma / GED

Strumenti

MS Office

Descrizione del lavoro

Gold Coast Health Plan is seeking a dedicated professional to manage provider disputes and ensure compliant, timely resolution. The role involves researching claims and contracts, coordinating with multiple departments, and maintaining accurate documentation.

Ideal candidates will have knowledge of Medi-Cal/Medicare, CMS guidelines, and strong communication skills. California residency is required for this position.