Claims Dispute Analyst
About The Position
The Claims Dispute Analyst ensures compliance with regulatory requirements for provider dispute matters by investigating and resolving provider claim appeals and requests for adjustments. The analyst addresses provider disputes in accordance with CHG protocols and applicable regulatory requirements. The role works with relevant departments to ensure processes, programs, and services are completed timely and efficiently in accordance with CHG policies and procedures and applicable state and federal regulations, including CMS and Medi-Cal. The position is based at the Corporate Headquarters in Chula Vista, California, and is full-time.
Requirements
- High school diploma or equivalent training.
- Five years of experience involving dispute resolution and claims adjudication.
- Strong knowledge of AB1455 regulatory requirements.
- Knowledge of CPT and ICD-10 coding and medical terminology.
- Knowledge of claims dispute determination and resolution procedures and coding practices.
- Ability to read, analyze, and interpret regulations and contract language.
- Excellent customer service skills.
- Good technical writing skills.
- Good judgment and problem-solving skills.
- Ability to work as a team player and independently.
Nice To Haves
- Bachelor's degree preferred.
Responsibilities
- Investigate and resolve provider claim appeals and adjustment requests across all product lines.
- Evaluate appellant documentation and determine whether the initial claim was paid in accordance with provider contract terms or established reimbursement guidelines.
- Adhere to contractual requirements established by regulatory agencies and interpret policies and procedures from internal departments, including Claims, Health Care Services, and Member Services.
- Meet requirements specified in the Provider Dispute Resolution policy and procedure.
- Determine claim appeal outcomes, including payment, reduction, or denial, based on case research and investigation.
- Document relevant case facts in the internal Provider Dispute Module and QNXT.
- Thoroughly review provider disputes and present recommendations.
- Maintain a professional image and contribute to team efforts, including participating in committees and meetings and performing other assigned or requested duties.
- Work with relevant departments to ensure processes, programs, and services are timely, efficient, and compliant with company policies and applicable regulations.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
