Provider Dispute Specialist

Job Summary

A company is looking for a Provider Dispute Resolution Specialist.

Key Responsibilities:

• Properly distinguish between provider disputes and appeals, update tracking systems, and process claim determinations accurately
• Review and process provider appeals according to regulatory guidelines, correspond with delegated entities, and prepare documentation for adverse determinations
• Identify denial trends, assist in audits, participate in training, and support process improvement initiatives

Required Qualifications:

• 3+ years of experience processing Medicare Advantage provider appeals and examining medical claims
• High School Diploma required, Bachelor's Degree in related field preferred
• Working knowledge of claims processing systems, medical terminology, coding, and payment methodologies
• Familiarity with billing and coding edits, MA Organization procedures, and Microsoft Office programs
• Ability to use 10 keys and understand Division of Financial Responsibility in claims processing