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 CalOptima policies and procedures that apply to claims adjudication and adjustment of claims when processing provider disputes. Works closely with claims management and trainer to identify training opportunities from trend reports. Processes Medi-Cal, OneCare and Healthy Families Provider Dispute Resolutions.
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.
- Notifies the 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 duties as assigned.
Required Skills
- Meet and maintain established quality and production standards.
- Work independently and as part of a team.
- Develop and maintain effective working relationships with all levels of staff and providers.
- Handle multiple tasks and meet deadlines.
- Effectively utilize computer and appropriate software (Excel, Word) and interact as needed with CalOptima Claim Processing Systems.
- Meet stated expectations and take responsibility for achieving results.
- Research and identify issues and problems, develop solutions, and prepare recommendations, including policies and procedures.
- Project management skills, well organized, and detailed oriented.
- Effectively communicate both in writing and verbally.
Required Experience
EXPERIENCE & EDUCATION:
- Bachelor’s degree in Claims Administration or a related field; or an equivalent combination of education and work experience is required.
- 2+ years experience processing on-line claims in a managed care and/or PPO/indemnity environment that would provide the knowledge and abilities listed is required.
- Medical Terminology, CPT-4, HCPC, Revenue Codes, and ICD-9/ICD-10 required.
- Both Medicare and Medi-Cal billing and claims adjudication experience required.
- Experience in claims billing systems.
KNOWLEDGE OF:
- 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.
Grade: I
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