Provider Dispute Resolution Claims Examiner II

Job Summary

The Provider Dispute Resolution Claims Examiner (PDR) II is responsible for the accurate analysis and resolution determination of provider disputes from all sources.  Extensive knowledge of LA Care Direct services. Responds to provider inquiries related to claims payments and ensuring all PDR documents are processed timely with timely submission of all resolution letters.

Duties

Process all types of claims with focus on L.A. Care direct services. Claims are accurately processed within the applicable contractual or regulatory time frames. Meet production and quality standards set by PDR Claims Department Management. Timely and accurate process of standard PDR claims for all lines of business. Audit claims for excessive charges, duplicates, unbundling, and medical up coding. Resolve provider claims payment disputes. Issues are resolved within the specific time frame as required by regulatory agencies and as supported by departmental policies. (60%)

Identify and report PDR trends to management for process improvement opportunities. (15%)

Work with internal departments to resolve issues preventing claims processing or to enhance processing effectiveness. May assist in testing, changing, analyzing and reporting of specific enhancements. (15%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes.

Preferred:  
Experience processing PDR documents.

Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.

Skills

Required:
Ability to operate PC-based software programs or automated database management systems. 

Strong communication skills with excellent analytical and problem- solving skills.

Ability to self-manage in a fast-paced, detail-oriented environment.

Moderate knowledge of Microsoft Word and Excel.

Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials(Provider Dispute Resolution (PDR), Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)-10 coding guidelines), and complete product and Coordination Of Benefits (COB) knowledge. 

Persuasion Skills: Persuading co-workers and management to accept recommendations for work flow or procedural changes to support process improvement efforts. In cases of provider payment dispute, Convincing the provider that their claims have been handled properly bases on the provider contract or regulatory guidelines.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Financial Impact: Coordinating with Utilization Review and Provider Network Operations on the negotiation of  reimbursement arrangements with non-contracted and out-of-area providers to avoid paying billed charges.