Provider Dispute and Resolution Analyst III

L.A. Care Health Plan•Los Angeles, CA

3d•$77,265 - $123,625

About The Position

The Provider Dispute and Resolution Analyst III independently manages complex provider claims and reimbursement disputes, ensuring payments align with contractual obligations through advanced analysis of claims, contracts, and provider data. The role conducts root-cause analyses to resolve systemic issues, coordinates cross-functional resources, and supports non-litigation settlements by validating disputed amounts and preparing documentation. As subject matter expert Analyst delivers clear case summaries, maintains professional provider communication, and promotes continuous improvement and technical guidance within the team. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Requirements

At least 3 years of experience in managing complex provider claims and reimbursement disputes within a healthcare or managed care environment.
Experience interpreting contract terms, analyzing claims data, and resolving financial discrepancies is essential.
Experience coordinating cross-functional teams including Claims, Configuration, Finance, Legal, and Compliance. is critical for addressing multifaceted issues and implementing sustainable solutions.
Advance knowledge of root-cause analysis and systemic process improvement.
Skills include advanced analytical abilities to synthesize large volumes of claims and provider data, strong attention to detail, and the capacity to evaluate disputed payments against contractual obligations.
Excellent written and verbal communication skills to prepare concise case summaries and maintain professional, objective interactions with providers during sensitive financial disputes.
Ability to manage multiple concurrent disputes, prioritize tasks, and deliver actionable recommendations is vital.
Strong technical skills and proficiency with claims processing systems and documentation tools.
Collaboration skills, accountability, and sound decision-making.

Nice To Haves

Experience supporting non-litigation settlements, including validating disputed financial amounts and preparing comprehensive documentation for review and approval.
Ability to demonstrated leadership in continuous improvement initiatives, share best practices, and provided technical guidance to junior staff will be well-positioned for success.

Responsibilities

Acts as an enterprise resource, entrusted with independently managing the full lifecycle of complex provider claims and reimbursement disputes—from initial intake through final resolution and provider communication.
Research and synthesize claims, payment histories, contract terms, reimbursement exhibits, system configurations, and provider data, ensuring that all disputed payments are rigorously evaluated against contractual obligations.
Conducts structured root-cause analyses of recurring system reimbursement issues, proactively addressing underlying causes to drive sustainable improvements.
Manages multiple concurrent disputes often involving significant claim volumes, financial exposure, and provider sensitivity the Analyst develops actionable findings and resolution recommendations, frequently coordinating cross-functional resources across key stakeholders.
Validates disputed financial amounts at both line-level and aggregate, preparing comprehensive documentation for settlement review and approval, and ensuring seamless downstream processing with Claims and Finance.
Prepares concise case summaries for significant provider escalations, articulating issue history, claim volume, contractual basis, financial exposure, root cause, and recommended resolution.
Maintains professional and objective communication with providers, serving as a trusted point of contact.
Responsible for continuous improvement, and identifying opportunities.
Elevates the organization’s capacity to resolve provider disputes efficiently, accurately, and with lasting impact.
Apply subject matter expertise in evaluating business operations and processes.
Identify areas where technical solutions would improve business performance.
Consult across business operations, provide mentorship, and contribute specialized knowledge.
Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices.
Provide training and recommend process improvements as needed.
Performs other duties as assigned.