Provider Dispute and Resolution Analyst II

L.A. Care Health Plan•Los Angeles, CA

3d•$67,186 - $107,498

About The Position

The Provider Dispute and Resolution Analyst II researches, analyzes, coordinates, and resolves routine to moderately complex provider claims, payment disputes, and reimbursement issues for contracted network providers. The role reviews claims, payment information, contract terms, configuration, and supporting documentation to determine appropriate resolution pathways, following established policies, workflows, reimbursement guidance, and escalation protocols. The analyst works with internal stakeholders and provider representatives to resolve concerns and coordinate corrective claim actions. The position provides analytical and administrative support for non-litigation provider settlement activities, including claim research, payment validation, reconciliation, preparation of documentation for settlement evaluation, and tracking approved resolution activity. The Analyst II independently handles routine and moderately complex matters and escalates higher-risk, systemic, financially significant, contractually ambiguous, or otherwise unresolved disputes to appropriate leadership. The role also maintains case records, communicates findings and resolution status to providers, and contributes to continuous improvement and collaborative practices.

Requirements

At least 2 years of experience researching, analyzing, coordinating, and resolving provider claims, payment disputes, and reimbursement issues in a healthcare or managed care environment.
Experience reviewing provider claims, payment information, contract terms, and supporting documentation to determine an appropriate resolution pathway.
Experience working within established policies, workflows, reimbursement guidance, and escalation protocols.
Experience partnering with Claims, Configuration, Finance, and provider contract representatives to resolve provider concerns and coordinate corrective claim action.
Strong analytical abilities to research and resolve provider claims and reimbursement disputes.
Meticulous record-keeping, effective cross-functional collaboration, and adherence to established dispute resolution policies.
Clear, objective communication skills for provider interactions, timely escalation of complex cases, and commitment to continuous improvement and accountability.
Associate's degree; equivalent education and/or experience may be considered in lieu of a degree.
Ability to travel to offsite locations for work.

Nice To Haves

Experience preparing documentation for settlement evaluation.
Advanced analytical support for settlement reviews.
Ability to escalate unresolved items to senior leadership, share best practices, and promote decision quality.
Leadership skills that foster collaboration and drive organizational progress.

Responsibilities

Research and resolve routine to moderately complex provider claims, payment disputes, and reimbursement issues.
Review claim histories, provider documentation, payment information, contract terms, configuration, and supporting materials to determine appropriate resolutions.
Validate disputes against contractual rates and payment mechanisms in collaboration with relevant stakeholders.
Coordinate corrective claim actions and document remediation activities.
Maintain accurate case records and provide timely, transparent, objective communication to providers about findings and resolution status.
Escalate disputes that exceed established complexity or financial thresholds, or involve systemic, financially significant, contractually ambiguous, or unresolved issues.
Research claims and payment histories, reconcile disputed inventories, prepare documentation for settlement evaluation, and track approved settlement activities.
Identify and escalate discrepancies or unresolved settlement items.
Support and apply dispute resolution policies, workflows, and frameworks.
Promote continuous improvement, share best practices, and support accountability, collaboration, and decision quality.
Perform other duties as assigned.