Job Title: Provider Dispute Resolution Specialist
Department: Operations – Claims

About the Role:

We are currently seeking a highly motivated Provider Dispute Resolution Specialist. This role will report to the Sr. Director - Operations and enable us to continue to scale in the healthcare industry. This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

What You'll Do:

• Conducts analyses related to claims processing activities and determines root causes of claims suspensions and payment errors
• Determines whether issues are due to claims data lifting, in-load process, system configuration, contract interpretation or training related
• Collaborates with other departments such as Provider Data Management, Provider Relations, Term and condition, Eligibility Department, Benefit Department and Utilization Management to ensure successful resolutions of claims issues
• Assists in processing claims payment review/reconciliation resulting from settlements and/or retro-active effective date of the provider contracts
• Assists in the implementation of new projects related to claims processing
• Perform other duties as necessary or assigned by NMM’s management team
• Proficient in and knows how to use and apply Health Plan Benefit Matrices and DOFR (Division Of Financial Responsibility)
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to health plan operations or as documented in company policies and procedures
• Proficient understanding of AB1455 Claims Settlement Practice & dispute and resolution regulations
• Understand the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in the appropriate applications to support the accurate & timely payment of claims
• Maintain knowledge of all ICD-10, CPT, HCPC codes, general billing procedures for health care providers and institutions, as well as Medicare and Medi-Cal reimbursement guidelines
• Knowledge of rate application for all outpatient and inpatient facility, ASC, APR-DRG, DRG, interim rate, 3M Core Grouping and CMAC rates of payment methods to appropriated line of business. (Medicare, Medi Connect, Commercial and Medi-Cal)
• Identify any incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication
• Track and analyze claims adjudication errors
• Flexibility to accept special and/or ad hoc projects
• Adhere to corporate standards for performance metrics, data integrity, and reporting format to ensure high quality, meaningful output and the strictest confidentiality at all times
• Support the Claims Department as business needs require
• Comply with claims timeliness guidelines: Commercial 45 working days; Medi-Cal 30 calendar days; Medicare non-contracted 30 calendar days and Medicare contracted 60 calendar days. Identify any overpayment underpayment in a review and or history search and Collaborate with Recovery Analyst on any type of overpayment on a claim
• Ability to clearly communicate medical information to professional practitioners and/or the general public
• Detailed knowledge of medical coding systems, procedures, and documentation requirements
• Ability to adapt and modify medical billing procedures, protocol, and data management systems to meet specific operating requirements
• Recognize claim correspondences from multiple IPAs
• Recognize the difference between Shared Risk and Full Risk claims
• Attendance at employer worksite is an essential job requirement
• Work assigned claim project to completion

Qualifications:

• Knowledge of MS Word, Excel, EZ-CAP, Virtual AuthTech, Encoderpro and other basic medical terminology
• Typing speed 50+ WPM and knowledge of 10 key desired
• At least 5 year of experience in managed health care environment related to claims processing
• Associate’s degree (A.A.) or at least 5 years complex claims processing experience in the health insurance industry or medical health care delivery system
• Bachelor's degree (B. A.) from four-year college or university
• EZ-CAP knowledge; or equivalent combination of education and experience
• At least 5 years of experience in managed health care environment related to claims processing
• Must be PC proficient and able to thrive in a fast-paced setting

You're great for this role if:

• Ability to multi-task and meet deadlines
• Strong organization skills; ability to multitask and properly manage time
• Position may require unscheduled overtime, weekend work
• Ability to understand work with proprietary software applications
• Organizational ability and ability to exercise good judgment
• Work independently as part of a team
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems

Who We Are:

ApolloMed (NASDAQ: AMEH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.

Our platform currently empowers over 10,000 physicians to provide care for over 1.2 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.

Our Values:

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity and Excellence
• Be Innovative
• Work as One Team

Environmental Job Requirements and Working Conditions:

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1668 S Garfield Avenue, Alhambra, CA 91801

ApolloMed is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@networkmedicalmanagement.com to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.