Job ID# 1008511 – Posted 2/24/2023 – Los Angeles, CA

The Provider Dispute Resolution Claims Examiner is responsible for:

– The accurate analysis and resolution determination of Provider Disputes from all sources.
– Assist in the resolution of eligibility, benefit, contracting, and payment schedule issues.
– Handle and document resolution to escalated telephone and written appeals.
– Ensuring all PDR documents are processed timely with timely submission of all acknowledgement and resolution letters
– Timely processing of complex PDR claims for all lines of business
– Auditing claims for excessive charges, duplicates, unbundling, and medical up coding
– Maintaining department databases used for report production and tracking on-going work
– Assisting management with in-house and on-site training as offered to employees and providers.

– At least 1-2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes.
– Experience processing PDR documents
– Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.
– Ability to self-manage in a fast-paced, detail-oriented environment.
– Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials(PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.
– Moderate knowledge of Microsoft Word and Excel.

Associate’s Degree

Please send your resume and any additional information to our recruitment team at recruitment@nexlogica.com