Provider Disputes Team Lead

Responsibilities:

Responsible for research and analysis related to provider issues documented as provider disputes. Responsible for identifying systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues and routing provider disputes to appropriate stakeholders for resolutions within contractual timeframes. Responsible for ensuring the Plan stays in compliance with provider contracts as it relates to provider disputes. Under supervision of the Provider Network Operations Supervisor, the Lead, Provider Disputes performs administrative tasks, included but not limited to, Fax Management (storage and distribution), letter processing and storage, data collection and assembling/filing completed disputes within provider folders within EXP.

• Triage provider disputes and route to appropriate stakeholders for resolutions within the contractual timeframes.

• Retrieves faxes from the electronic fax system, creates provider dispute SFs and route through EXP to the appropriated departments for resolution.

• Responsible for tracking fax volume received on a department-wide basis and for individual team members on a daily, weekly, and monthly basis.

• Assure provider disputes are resolved or provide responses within the contractual timeframe.

• Provides feedback to Provider Network Analysts and Account Executives, management and corporate staff relative to error trending and resolution.

• Acts as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers.

• Monitors and reports provider disputes correspondence, dispute forms and EXP Service Forms.

• Participates with Corporate Operations Team to provide research and resolution to issues.

• Communicates updates and impact of changes to internal stakeholders as appropriate.

• Performs quality assurance activities to ensure statutory reporting accuracy, appropriate dispute resolution and operational efficiency of the provider disputes process.

• Create Provider Dispute reports with documented resolutions for State reporting.

• Other duties as assigned by management.

Education/Experience:

• Bachelor's Degree or equivalent combination of education and experience with emphasis in health services administration, information systems, medical office administration and/or claims administration, Medicaid and Medical billing, payment and reimbursement.

• Certified Professional Coder (CPC/CPT/HCPC ) preferred.

• 3-5 years healthcare environment operational experience including claims, configuration, claims analysis, provider contracting or any appropriate combination of these required.

• 3-5 years experience and demonstrated mastery of relational databases, reporting, development and analysis, using Microsoft Access or similar system, at a level relevant to and appropriate to carrying out Provider Network Analyst responsibilities required.

• Formal training or equivalent experience in the effective use of reporting and querying software such as MS Excel, MS Access, BI Query, Crystal Reports and/or SQL required.

• Claims processing and Provider data maintenance knowledge required.

• Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required.This would include experience with Facets or similar applications and their supporting database schema and structure.