Provider Dispute Specialist

Job Summary

To support a growing health plan, the full-time remote Provider Dispute Specialist will manage provider dispute resolution and claim adjustment processing, ensuring compliance with regulatory requirements while conducting thorough research and analysis of claims.

Key Responsibilities

• Manage provider disputes from intake to resolution, adhering to regulatory timeframes and internal SLAs
• Conduct in-depth research and analysis of claims, contracts, and regulations to determine appropriate outcomes
• Initiate and process claim adjustments for valid disputes, ensuring accurate corrections in claims processing systems

Required Qualifications

• 3-5 years of experience in a commercial health plan or managed care organization with a focus on provider dispute resolution
• Strong knowledge of claim adjudication principles, including familiarity with CPT, HCPCS, and ICD-10 codes
• Exceptional written communication skills for drafting provider-facing correspondence and determination letters
• Proficiency in case management platforms (e.g., Salesforce) and claims processing systems
• Understanding of state and federal regulations governing provider disputes and claims