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Provider Dispute Resolution Claims Examiner II

Job Category:  Claims
Department:  Claims Integrity

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8273


Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Provider Dispute Resolution Claims Examiner II is responsible for:
* The accurate analysis and resolution determination of Provider Disputes from all sources.
* Assist in the resolution of eligibility, benefit, contracting, and payment schedule issues.
* Handle and document resolution to escalated telephone and written appeals.
* Ensuring all PDR documents are processed timely with timely submission of all acknowledgement and resolution letters
* Timely processing of complex PDR claims for all lines of business
* Auditing claims for excessive charges, duplicates, unbundling, and medical up coding
* Maintaining department databases used for report production and tracking on-going work
* Assisting management with in-house and on-site training as offered to employees and providers.


Processing claims for all products. Claims will be accurately processed within the applicable contractual or regulatory time frames. Meet production and quality standards set by PDR Claims Department Management. (30%)


Resolving member and provider claims payment disputes. Issues will be resolved within the specific time frame as required by regulatory agencies and as supported by departmental policies. (20%)


Performs special projects and ad-hoc reporting as necessary. Projects will be complete and reports will be generated within the specific time frame agreed upon at the time of assignment. (15%)


Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (10%)


Working 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%)

Education Required

Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree


At least 0-2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes.


Experience processing PDR documents.


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


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.


Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials(PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.


Moderate knowledge of Microsoft Word and Excel.


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

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. 


L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.

Nearest Major Market: Los Angeles

Job Segment: Claims, Medicare, Insurance, Healthcare

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