Provider Dispute Resolution Specialist - Alignment Healthcare

Overview of the Role:

Alignment Health is seeking a provider dispute resolution specialist (“Specialist”) to join the claims and configuration team.  As a specialist, you will process provider appeals and disputes accurately and timely, assess and complete documentation for tracking / trending data, and conduct research to respond and process incoming provider appeals and disputes in accordance with all established CMS Medicare Advantage regulatory, contractual, and departmental guidelines. You will also process the claim(s) within the claim system while following department processes, interface with internal departments and external resources and organizations and prepare and assist with departmental reports as needed.

If you’re looking for an opportunity to join a growing organization, be a part of a talented team of professionals, while positively impacting the lives of seniors – we are looking for YOU!

Responsibilities:

1. Distinguish between a provider dispute and a provider appeal. Confirm each provider appeals are correctly identified for appropriate tracking and reporting
2. Update tracking system to ensure cases are processed timely and appropriate actions are taken
3. Review and process provider appeal and dispute determinations according to CMS, contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.
4. Correspond with delegated entity to obtain appropriate records or payment information
5. Prepare appropriate documentation and submit to IRE when provider appeals result in adverse determination and / or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
6. Process / adjudicate claim(s) according to departmental procedures
7. Meet and consistently maintain quality and productivity standards as defined by the leadership.
8. Identify denial or payment variance trends and escalate to department management for training opportunities and corrective action.
9. Assist in preparing and reviewing cases for regulatory and other health plan audits.
10. Participate in ongoing training to support company and department initiatives.
11. Support department initiatives in improving processes and workflow efficiencies
12. Adhere to all regulatory and company standards, as described in the employee handbook and departmental policies and procedures.
13. Comply with company’s time and attendance policy.
14. Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
15. Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.

Required Skills and Experience:

• Minimum 3 years’ experience processing Medicare Advantage provider appeals from all types of providers (hospitals, physicians, ancillary)
• Minimum 3 years’ experience in examining all types of medical claims, preferably Medicare Advantage claims
• High school required
• Bachelor’s degree in related field, a plus
• Experience with claims processing systems (EZCAP preferred).
• Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
• Familiar with different payment methodology such as Medicare PPS (MS-DRG, APC, etc.), Medicare Physicians fee schedule, Per Diem, etc.,
• Familiar with Division of Financial Responsibility on how they apply to claims processing
• Familiar with billing and coding edits, coordination of benefits, MA Organization, Determination, Appeals and Grievance procedures
• Possess problem-solving skills and able to translate knowledge to the department.
• Proficient in Microsoft Office programs (Outlook, Excel, and Word)
• Excellent written and verbal communication.
• Strong organizational skill and able to multitask
• Attention to detail.
• Able to type by 10-key touch.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and / or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the able to adjust focus.

PAY RANGE: $51,600 - $60,320 annually