Provider Dispute Resolution (PDR) Specialist Champion Health Plan Long Beach, CA Job Details Full-time From $26 an hour 12 hours ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance Life insurance Retirement plan Qualifications Research High school diploma or GED Full Job Description Job Overview Champion Health Plan of California is seeking a Provider Dispute Resolution (PDR) Specialist responsible for researching and resolving provider disputes related to claims payment, denials, reimbursement, and contract benefit interpretation. The PDR Specialist will utilize QuickCap, provider contracts, fee schedules, and supporting documentation to ensure disputes are accurately and timely resolved in accordance with applicable contractual, CMS, regulatory, and health plan requirements. Essential Duties and Responsibilities Research and resolve provider disputes involving claim payments, denials, underpayments, overpayments, and reimbursement. Research claims, payment history, adjustments, and denials within QuickCap. Review provider contracts, amendments, fee schedules, and reimbursement terms to validate appropriate payment. Analyze professional and institutional claims and applicable Medicare reimbursement methodologies. Research issues involving authorization, eligibility, coding, timely filing, bundling, and other claims-processing requirements. Determine whether claims should be upheld, adjusted, reprocessed, or referred for additional review. Prepare accurate provider dispute determinations and correspondence. Identify and escalate potential QuickCap configuration, fee schedule, or systemic claims issues . Coordinate with Claims, Provider Relations, Provider Contracting, Configuration, Utilization Management, Finance, and Compliance as needed. Maintain complete documentation and ensure disputes are resolved within applicable regulatory and contractual timeframes. Identify recurring dispute trends and escalate issues potentially affecting multiple claims or providers. Support audits, compliance reviews, and regulatory requests as needed. Qualifications 4+ years of Medicare Advantage, managed care, claims, provider disputes, reimbursement, or related health plan experience. QuickCap experience strongly preferred. Knowledge of Medicare Advantage HMO claims and provider reimbursement. Experience interpreting provider contracts and fee schedules preferred. Working knowledge of professional and institutional claims, CPT, HCPCS, ICD-10, revenue codes, and Medicare reimbursement. Strong analytical, problem-solving, documentation, and communication skills. Proficiency with Microsoft Office, particularly Excel. High school diploma or equivalent required; associate or bachelor's degree preferred.

Preferred Experience Medicare Advantage QuickCap Provider Disputes Claims Adjudication Provider Contracts Medicare Fee Schedules Claims Adjustments/Reprocessing Provider Reimbursement Pay:

From $26.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Retirement plan Vision insurance

Work Location:

In person