Provider Dispute Resolution Specialist

To process provider disputes according to governmental and Health Plan regulations.

Professional Duties

• Review and acknowledge disputes and requests additional information within 15 business days.
• Review and prepare Utilization Management (UM) Appeal packets per internal process and submits to the UM or Case Management Department.
• Assure that payment or denial of provider dispute resolutions (PDR)is processed within 45 business days.
• Assure that payment is made within 5 days of determination of approval.
• Maintain and update PDR, Appeal and UM Appeal Log and retain 2 years of PDR on site.
• Participate in the claim re-open process.
• Remain abreast of revisions to the PDR process and updated language on acknowledgement letters.
• Communicate with providers and Health Plans in a timely and appropriate manner.
• Examine, enter and adjudicate PDR claims for accuracy, completeness, authorization, referrals and eligibility benefits.
• Utilize knowledge of health maintenance organization (HMO) and provider contracts, Managed Care Operations, Health Plan benefits and Division of Financial Responsibility for accurate decision making.
• Complete the audit preparation process thoroughly and in an organized manner.
• Assure that approved UM appeals are sent for claims adjustments.
• Assure that providers are notified of appeal determinations.
• Notify claims management team of recurring incorrect payment patterns and other areas of improvement opportunities.
• Perform other duties as assigned.
• Serve as an ambassador for Desert Oasis Healthcare and Family Hospice Care at all times and positively shape the customer experience
• Introduce self and your role
• Be knowledgeable about your job so that you can serve others effectively
• Be sensitive to factors that influence customers and co-worker’s situation including age, gender, culture, race and socioeconomic status. Be observant of others’ social cues (emotions) and respond appropriately
• Speak clearly and use understandable language (avoid medical jargon or slang)
• Summarize key information and provide written materials whenever possible
• Demonstrate appropriate body language and tone of voice
• Answer all phone calls with a salutation, introduction and offer to assist (Good afternoon, Desert Oasis Healthcare or Family Hospice Care, this is (your name), how may I help you?)
• Speak positively about your work, co-workers and Desert Oasis Healthcare and Family Hospice Care
• See the positive in situations and in others
• Avoid gossip and negativity
• Offer to answer any additional questions that the person, patient or customer may have

Qualifications

• High School Diploma or equivalent.
• 2 years of claims processing experience.
• Knowledge of Medicare rules, medical terminology, and managed care health plan rules and regulations, ICD-10, CPT, and RVS codes.
• Ability to utilize electronic office equipment such as computer, copy machine, etc.
• Detail oriented and strong organizational skills. Ability to multitask and reprioritize work to meet deadlines.
• Ability to effectively communicate with individuals within all levels of the organization and individuals from other organizations.

Physical Demands

• Sitting: Approximately 70% of day
• Standing: Approximately 15% of day
• Walking: Approximately 15% of day
• Lifting: 0 - 10 lbs (equipment, supplies) - approximately 5% of day
• Bending: Approximately 10% of day. Kneeling < 10%.
• Hearing/Visual Acuity: Adequate for use with computers, telephone and or Blackberry -

Approx 50% of day

• Computer: Highly technical work environment - Must be able to work ≥ 7 hours / day using keyboard, mouse and monitor
• Reaching: Above head 75 degrees - approximately 5%.
• Hand grip dexterity: Approximately 40% of day