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Claims Resolution Specialist

Location : Orange, CA
Job Type : Temp/Contract
Job Industry : Healthcare - Health Services

Job Description :


Job Summary


The Claims Resolution Specialist, Provider Dispute Resolution (PDR) is responsible for overseeing and managing the PDR process. The incumbent is responsible for following regulatory and internal guidelines in conjunction with company policies and procedures that apply to claims adjudication and adjustment of claims when processing provider disputes.  The incumbent will work closely with claims management and trainers to identify training opportunities from trend reports. The incumbent will also process Medi-Cal and OneCare.

Position Responsibilities:

  • Responsible for accurate and timely adjudication of PDR claims according to AB1455 regulatory guidelines.

  • Processes resolutions based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claim processing guidelines and company policies and procedures.

  • Informs Supervisor or Manager of issues impacting production and quality (i.e., incorrect database configurations, non-compliant PDR, etc.).

  • Responds to incoming calls from providers of service relating to PDR.

  • Analyzes, processes, researches, adjusts all provider reconsideration requests and correspondence.

  • Other projects and duties as assigned.

Possesses the Ability To:

  • Maintain established quality and production standards.

  • Work both independently and as part of a team.

  • Develop and maintain effective working relationships with all levels of staff and providers.

  • Display project management skills while being well-organized and detailed oriented.

  • Handle multiple tasks and meet deadlines.

  • Meet stated expectations and take responsibility for achieving results.

  • Research and identify issues and problems, develop solutions, and prepare recommendations, including policies and procedures.

  • Communicate clearly and concisely, both verbally and in writing.

  • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Required Qualifications :


Experience & Education:

  • High School degree or equivalent required.

  • 2+ Years of experience processing on-line claims in a Health Care / Managed Care setting specifically in adjudicating and adjusting claims required.

  • 1+ Year of experience in both Medicare and Medi-Cal billing required.

Preferred Qualifications:

  • Bachelor’s degree in Business Administration, Health Care Management, or related field preferred.

  • Previous experience in claims billing systems preferred.

Knowledge of:

  • Medical Terminology, Current Procedural Terminology (CPT-4), Healthcare Common Procedure Coding (HCPC), Revenue Codes, and International Classification of Diseases (ICD-9/ICD-10).

  • Claims processing rules, Managed Care Benefits, and adjudication.

  • Claims administration, including medical terminology, CPT, Revenue Codes, ICD-9/ICD-10 and HCPS codes.

  • Medicare and Medi-Cal requirements/regulations and AB1455 guidelines.

  • Methods and techniques for organizing and implementing programs or projects.

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