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Provider Dispute Resolution Specialist

81% Flex

EXTRA HOLIDAYS - EXTRA PARENTAL LEAVE

Remote:

Full Remote

Salary:

30 - 69K yearly

Experience:

Mid-level (2-5 years)

Work from:

Canada, California (USA), United States

Offer summary

Qualifications:

3-5 years' experience as a Claims Examiner with Medicare and HMO proficiency., Knowledge of medical terminology, ICD9, ICD 10, CPT4, UB04, CMS 1500 Forms..

Key responsabilities:

Interpret provider contracts for correct claim payment or denial.
Identify issues affecting claims processing efficiency, resolve and document.
Communicate clearly with providers regarding dispute resolutions.
Maintain quality and quantity standards for appeals.
Update Provider Dispute Database with resolution outcomes.
Request special check runs to ensure compliance.

NTT DATA Information Technology & Services XLarge https://www.nttdata.com/

10001 Employees

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Job description

Your missions

About NTT DATA
NTT DATA is a $30+ billion trusted global innovators of business and technology services. We serve 75% of the Fortune Global 100 and are committed to helping clients innovate, optimize and transform for long-term success. As a Global Top Employer, we have diverse experts in more than 50 countries and a robust partner ecosystem of established and start-up companies. Our services include business and technology consulting, data and artificial intelligence, industry solutions, as well as the development, implementation and management of applications, infrastructure, and connectivity. We are also one of the leading providers of digital and AI infrastructure in the world. NTT DATA is part of NTT Group, which invests over $3.6 billion each year in R&D to help organizations and society move confidently and sustainably into the digital future. Visit us at us.nttdata.com .

NTT DATA's Client is seeking a Provider Dispute Resolution Specialist to review written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims.

Provider Dispute Resolution Specialist - El Segundo, CA - 24-02056
W2 only
Remote
16 + months project

Job Duties/Responsibilities:

Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers.
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable.
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.
Plan and organize workload to ensure efficient and compliance resolution of issues.
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to ensure compliance
Warning reports are monitored daily to ensure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455.
Maintain minimum standards set for the department for quality and quantity of appeals received
Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.
Any other assigned duties and delegated by the Management.

Basic Qualifications:

3-5 years’ experience as a Claims Examiner with previous Medicare and HMO experience.
Working knowledge of medical terminology, ICD9, ICD 10, CPT4, HCPCs
Working knowledge of UB04 and CMS 1500 Forms
Ability to effectively interpret provider contract language and provisions
Extensive HMO knowledge
Familiar with AB1455, Knox Keene Act, Federal Register and Medicare Guidelines
Xcelys Claims platform experience preferred
Previous auditing and appeals experience preferred

Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The starting pay range for this role is $15.50 - $16.00/hour. Actual compensation will depend on several factors, including the candidate’s relevant experience, technical skills, and other qualifications. This position may also be eligible for incentive compensation based on individual and/or company performance.

This position is eligible for company benefits including participation in medical, dental, and vision insurance, flexible spending or health savings account, and AD&D insurance, employee assistance, participation in a 401k program, and additional voluntary or legally required benefits.

NTT DATA is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.