Blue Shield Of California
Provider Dispute Resolution Coordinator, Intermediate
Blue Shield Of California, El Dorado Hills, California, United States, 95762
Job Description
Your Role
The Provider Dispute Resolution Team is looking for an Intermediate Provider Dispute Resolution Coordinator that can research, review and adjust high priority and high dollar provider grievances, appeals and complaints, while clarifying issues and educating providers in the process for the No Surprise Billing mandate. The Intermediate Provider Dispute Coordinator will report to the PDR Operations Manager. In this role, the coordinator should be able to make independent decisions and appeal determinations. The candidate should effectively manage their time and prioritize their workload to ensure compliance timeframes and project deadlines are met.
Responsibilities
Your Work
In this role, you will: Process provider appeals and correspondence associated with policies, procedures and provider functions Monitor payments and fees for Independent Dispute Resolution Entities Support Open Negotiation process for the No Surprise Billing mandate Administrative tasks include, but not limited to, managing team email box, checking for expired links, forwarding emails, and redacting EOBs Proactively identify issues and execute corrective action on provider appeals Identify and triage appeals to appropriate areas Respond in writing to providers regarding appeal outcomes Make independent and final determination based on review of provider dispute Demonstrate flexibility, adaptability and support change in business needs to improve team performance Independently use available resources, documentation and tools Effectively partner with vendor teams and other departments Qualifications
Your Knowledge and Experience
Requires a high school diploma or GED Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination. Requires claims processing, including adjustments, interest accuracy proficiency, general suspense and back-end claims experience. Strongly preferred experience in Commercial LOB claims and/or appeals Preferred experience in Medi-Cal and/or Medicare LOB claims and/or appeals Preferred experience in No Surprise Billing Preferred knowledge of applicable legislation/regulations and compliance. Preferred knowledge of following systems - Facets, DocDNA, Smartcomm, Documentum, CLMS, CMS Pricers = 3M Pricer, DRG Pricer, SNF Pricer, CareWebQI. Strong skill set of Microsoft Office applications Demonstrated experience with free format letter writing
Your Role
The Provider Dispute Resolution Team is looking for an Intermediate Provider Dispute Resolution Coordinator that can research, review and adjust high priority and high dollar provider grievances, appeals and complaints, while clarifying issues and educating providers in the process for the No Surprise Billing mandate. The Intermediate Provider Dispute Coordinator will report to the PDR Operations Manager. In this role, the coordinator should be able to make independent decisions and appeal determinations. The candidate should effectively manage their time and prioritize their workload to ensure compliance timeframes and project deadlines are met.
Responsibilities
Your Work
In this role, you will: Process provider appeals and correspondence associated with policies, procedures and provider functions Monitor payments and fees for Independent Dispute Resolution Entities Support Open Negotiation process for the No Surprise Billing mandate Administrative tasks include, but not limited to, managing team email box, checking for expired links, forwarding emails, and redacting EOBs Proactively identify issues and execute corrective action on provider appeals Identify and triage appeals to appropriate areas Respond in writing to providers regarding appeal outcomes Make independent and final determination based on review of provider dispute Demonstrate flexibility, adaptability and support change in business needs to improve team performance Independently use available resources, documentation and tools Effectively partner with vendor teams and other departments Qualifications
Your Knowledge and Experience
Requires a high school diploma or GED Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination. Requires claims processing, including adjustments, interest accuracy proficiency, general suspense and back-end claims experience. Strongly preferred experience in Commercial LOB claims and/or appeals Preferred experience in Medi-Cal and/or Medicare LOB claims and/or appeals Preferred experience in No Surprise Billing Preferred knowledge of applicable legislation/regulations and compliance. Preferred knowledge of following systems - Facets, DocDNA, Smartcomm, Documentum, CLMS, CMS Pricers = 3M Pricer, DRG Pricer, SNF Pricer, CareWebQI. Strong skill set of Microsoft Office applications Demonstrated experience with free format letter writing