Dispute Resolution Specialist

Job Summary

Resolving first-level disputes related to claim payments and contractual agreements, the remote Dispute Resolution Specialist will manage claim records, process acknowledgment letters, and collaborate with internal teams to ensure compliance and provider satisfaction.

Key responsibilities:

• Examine claim records to investigate and resolve disputes while meeting quality and production standards
• Process acknowledgment and determination letters, providing detailed documentation of actions taken
• Create correspondence for the Senior Examiner and work with leadership on trends related to improper processing

Required qualifications:

• High school diploma or equivalent; professional experience may substitute
• Experience in a Managed Care Plan (MCP) or PACE organization claims processing environment
• Minimum of three years in health plan claims processing and two years in claims dispute resolution
• Strong knowledge of computer applications, including Excel, Outlook, and job-specific systems
• Ability to navigate state/federal websites and medical billing guidelines for claims resolution