Provider Dispute Resolution Lead

Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best. If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure. About this role: This role is open to California residents only. Reasonable Accommodations Statement To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Serves as the department subject matter expert for complex provider disputes, claims adjustments, reimbursement methodologies, and provider payment issues. Researches and resolves complex provider disputes in accordance with regulatory requirements, contractual obligations, claims processing guidelines, and organizational policies and procedures. Provides technical guidance, support, and coaching to PDR staff regarding dispute investigation, claim adjudication, contract interpretation, and resolution activities. Assists with daily workflow coordination, inventory monitoring, workload balancing, and identification of aging inventory requiring escalation or intervention. Monitors provider dispute inventory and communicates operational concerns, compliance risks, backlog trends, and workload issues to management. Assists management in maintaining compliance with Provider Dispute Resolution acknowledgment and resolution requirements, including AB1455 and other applicable regulations. Performs quality reviews of provider dispute work products and provides feedback, coaching, and recommendations for improvement. Identifies recurring dispute patterns, claim adjustment trends, provider concerns, configuration issues, and operational defects and escalates findings to management. Conducts root cause analysis of provider disputes and claim adjustment activity and assists with development of corrective action recommendations. Partners with Claims, Configuration, Network Management, Provider Relations, Compliance, Payment Integrity, and Information Technology to facilitate issue resolution and process improvements. Assists in development and maintenance of departmental job aids, standard operating procedures, training materials, and process documentation. Participates in provider meetings, internal workgroups, project meetings, and operational discussions related to provider dispute resolution and claims payment issues. Assists with onboarding and training of new PDR staff and provides ongoing peer mentoring and technical support. Assists with preparation, validation, and analysis of departmental reports, inventory metrics, operational trends, and regulatory compliance information. Maintains detailed and accurate case documentation and ensures appropriate records are maintained in accordance with organizational and regulatory requirements. Assists management in identifying opportunities to improve provider experience, reduce defects, improve payment accuracy, and enhance operational efficiency. Performs other duties as assigned.

MINIMUM QUALIFICATIONS

Education & Experience: High School Graduate or General Education Degree (GED) Minimum five (5) years of experience in claims processing, provider dispute resolution, claims analysis, payment integrity, provider reimbursement, or related managed care operations. Advanced knowledge of: Provider Dispute Resolution regulations and requirements, including AB1455. Claims adjudication processes and reimbursement methodologies. Medi-Cal, Medicare, and managed care operations. Medical billing and coding (CPT, HCPCS, ICD-10). Coordination of Benefits (COB) and Third-Party Liability (TPL). Provider contracts, payment methodologies, and Division of Financial Responsibility (DOFR). Equivalent in lieu of degree: Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position. 5 years of experience must be added in lieu of a bachelor's degree.

KNOWLEDGE, SKILLS & ABILITIES

Strong analytical, problem-solving, and investigative skills. Ability to interpret contracts, policies, regulations, and reimbursement methodologies. Ability to communicate complex information clearly and effectively to staff, providers, leadership, and business partners. Ability to prioritize work, manage multiple assignments, and meet regulatory deadlines. Ability to identify trends, operational risks, and opportunities for improvement. Ability to build effective working relationships across departments and with external stakeholders. Strong written and verbal communication skills. Ability to work independently while supporting team objectives and departmental goals. Technology & Software Skills: Advanced computer skills in MS Office products. Competency Statements Business Acumen - Ability to grasp and understand business concepts and issues. Decision Making - Ability to make critical decisions while following company procedures. Goal Oriented - Ability to focus on a goal and obtain a pre-determined result. Interpersonal - Ability to get along well with a variety of personalities and individuals. Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type. Time Management - Ability to utilize the available time to organize and complete work within given deadlines. Consensus Building - Ability to bring about group solidarity to achieve a goal. Relationship Building - Ability to effectively build relationships with customers and co-workers. Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions. Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards. Judgment - The ability to formulate a sound decision using the available information. Communication, Oral - Ability to communicate effectively with others using the spoken word. Communication, Written - Ability to communicate in writing clearly and concisely. Problem Solving - Ability to find a solution for and to deal proactively with work-related problems. The estimated pay range for the position is: $91,667.00 - $128,333.00 The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in. #J-18808-Ljbffr Gold Coast Health Plan