Provider Dispute Resolution Specialist

Provider Dispute Resolution Specialist Desert Oasis Healthcare•3.6 Palm Desert, CA Job Details Full-time $23.31•$28.92 an hour 1 day ago Qualifications Computer operation Medicare Regulatory compliance in claims processing High school diploma or

GED ICD-10

Task prioritization CPT coding Computer skills Medical terminology Cross-functional communication Full Job Description 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