Provider Dispute Resolution Claims Examiner II

Overview

Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members to ensure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

The Provider Dispute Resolution Claims Examiner (PDR) II is responsible for the accurate analysis and resolution determination of provider disputes from all sources. Demonstrates extensive knowledge of LA Care Direct services. Responds to provider inquiries related to claims payments and ensures all PDR documents are processed timely with timely submission of all resolution letters.

Education Required
Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred
Bachelor's Degree

Required:
At least 2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes.

Preferred
Experience processing PDR documents. Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations.

Required:
Ability to operate PC-based software programs or automated database management systems.
Strong communication skills with excellent analytical and problem-solving skills.
Ability to self-manage in a fast-paced, detail-oriented environment.
Moderate knowledge of Microsoft Word and Excel.
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (Provider Dispute Resolution (PDR), Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)-10 coding guidelines), and complete product and Coordination Of Benefits (COB) knowledge.

Persuasion

Skills:

Persuading co-workers and management to accept recommendations for work flow or procedural changes to support process improvement efforts. In cases of provider payment dispute, convincing the provider that their claims have been handled properly based on the provider contract or regulatory guidelines.

Licenses/Certifications Required

Licenses/Certifications Preferred

Physical Requirements: Light

Financial Impact: Coordinating with Utilization Review and Provider Network Operations on the negotiation of reimbursement arrangements with non-contracted and out-of-area providers to avoid paying billed charges.

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)