Provider Dispute Resolution Specialist

Essential Functions:

• Investigate, analyze, and resolve highly complex provider disputes involving reimbursement methodologies, contractual interpretation, and regulatory requirements.
• Serve as a subject matter expert providing technical guidance to Provider Dispute Resolution Analysts.
• Identify trends and make recommendations for corrective actions and process improvements.

Minimum Qualifications:

• High school diploma or GED required; Associate's or Bachelor's degree in related field preferred.
• Five years of progressively responsible experience in healthcare claims processing, provider dispute resolution, or related managed care environment.
• Knowledge of Medi-Cal, Medicare, D-SNP programs, medical billing and coding, and claims adjudication.

Preferred Qualifications:

• Experience with provider reimbursement methodologies, regulatory compliance, and providing technical guidance.
• Advanced computer skills in Microsoft Office applications.
• Valid driver's license and auto insurance.