Senior Provider Dispute Resolution Specialist

Ventura County Medi-Cal Managed Care Commission; California (MO); Hybrid; USD 52,000 - 73,000; Full time

Job summary

Gold Coast Health Plan seeks a Provider Dispute Resolution specialist to analyze and resolve highly complex disputes, focusing on reimbursement methodologies and regulatory compliance.

You will serve as a technical resource, guide analysts, monitor regulatory changes, and collaborate with Claims, Finance, and Compliance to improve payment accuracy.

Experience in Medi-Cal/Medicare and strong MS Office skills are preferred, with a commitment to service excellence and process improvement.

Qualifications

• Basic knowledge of Medi-Cal, Medicare, and DMHC requirements.
• Experience with claims adjudication, disputes, and provider payment processes.
• Familiarity with COB, TPL, and standard health plan operations.

Responsibilities

• Investigate and resolve highly complex provider disputes involving reimbursement and claims.
• Provide guidance to dispute analysts on research, adjudication, and payment methods.
• Review and research claims, contracts, and supporting docs to determine resolution.
• Assist in onboarding and training new dispute staff and ensure regulatory compliance.
• Prepare reports on dispute trends, operations, and performance.

Skills

MS Office

Education

High School Diploma or GED

Associate's or Bachelor's degree in Business Administration, Healthcare Administration, Finance, or related field

Job description

Gold Coast Health Plan seeks a Provider Dispute Resolution specialist to analyze and resolve highly complex disputes, focusing on reimbursement methodologies and regulatory compliance.

You will serve as a technical resource, guide analysts, monitor regulatory changes, and collaborate with Claims, Finance, and Compliance to improve payment accuracy.

Experience in Medi-Cal/Medicare and strong MS Office skills are preferred, with a commitment to service excellence and process improvement.