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Provider Dispute Resolution Intake Coordinator II

Job Category:  Provider Relations
Department:  Claims Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8035

 

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 Intake Coordinator II supports the PDR unit in acknowledging Provider Dispute Resolution requests sent by providers and maintains acknowledgement compliance as regulated by Centers for Medicare and Medicaid Services (CMS) and California Department of Managed Health Care (DMHC) guidelines. The position will research Provider Disputes submitted by contracted and non-contracted providers to identify original paid or underpaid claims in MHC and other systems.  
  Responsibilities include: 
  * Processing of incoming PDR’s via certified mail, USPS, faxes, emails and all other sources of delivery methods. 
  * The Provider Dispute Resolution intake staff sorts through PDR receipts to identify and correctly route provider issues to the following departments, Grievances and Appeals, Utilization Management, Medical Management, claims production floor and the PDR unit. 
  * Provider dispute resolution intake staff research and identify using MHC to identify original claim being disputed by the Provider using the Provider dispute resolution process according to AB1455. 
  * Provider dispute resolution intake staff are responsible for keying  PDR’s into SSO system.   
  * Provider dispute resolution  intake staff complete acknowledge letter and mail out correspondence letters to provider. 
  * Provider dispute resolution intake staff take receive calls that are forwarded from the member service department and claims provider call center regarding Provider dispute resolution inquiries. Intake staff follows up with provider regarding requested information and waiver of liability request forms that are sent on Medicare members.

Duties

Processing incoming PDR's via mail/fax/email/certified mail: Opening and date stamping the mail. received from various sources; Sorting and counting mail receipts; Tracking claims receipts and apprising the department manager of high volumes; Researching claims in MHC system to identify the appealed claim by the provider; Key-in claims daily into SSO system; Verification of member eligibility using the Managed Health Care system and/or the Medi-Cal Automated Eligibility Verification System (AEVS); Identifying and forwarding misdirected mail to the correct internal departments Ensure that paper claims and nonstandard documents are routed appropriately to internal departments within the required timeframe using SSO and interoffice delivery;  keeping track of Medicare member waiver request forms; Closing out cases if information has not been received in SSO. (40%)

 

Answering phone inquiries, providing clerical assistance to the claims PDR unit as needed. Provide cross-training to other PDR intake staff. Determine workloads and process flow to ensure compliance with the regulatory agencies. (25%)

 

Photocopying and mailing correspondence to submitting providers, PPGs, and other parties on a daily basis. Scanning/OCR uploading of PDR's and acknowledgement letters into SSO. (20%)

 

Maintaining individual production reports: maintained on EXCEL spreadsheets. (5%)

 

Perform other duties as assigned. (10%)

Education Required

High School Diploma/or High School Equivalency Certificate

Education Preferred

Experience

Required:
At least 0-6 months experience in a claims data entry and clerical position preferred in healthcare environment.

Skills

Required:
Proficient with Microsoft Office (Word, Excel).

 

Strong data entry and filing skills.

 

Professional telephone manner.

 

Excellent communication skills.

 

Strong customer service orientation to both internal and external customers. 

 

Must be dependable and able to prioritize and accomplish work with minimal supervision.

 

Must know Centers for Medicare and Medicaid Services(CMS) and Department of Managed Health Care (DMHC) timeliness requirement that pertain to AB1455 PDR Acknowledgment and resolution section.

 

Must enjoy working as part of a team.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information

 

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, Data Entry, Clerical, Medicare, Medicaid, Insurance, Administrative, Healthcare

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