Job Description

JOB SUMMARY

The Provider Dispute Resolution Specialist is responsible for the accurate, timely, and compliant review and resolution of provider disputes and appeals related to claims adjudication, reimbursement, coding, and authorization determinations. This role ensures compliance with applicable California state and federal regulations, contractual obligations, and internal policies while supporting positive provider relations.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High school diploma or equivalent.

Preferred: Coursework or training in healthcare administration, medical billing, or related field.

Experience

Minimum: 5+ years of experience processing managed care health claims.

Preferred: 2+ years of direct Provider Dispute Resolution and/or Appeals experience within Medicare, Medi-Cal/Medicaid, Commercial, PPO, and/or HMO environments.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

• Strong working knowledge of managed care claims operations and regulatory requirements, including dispute and appeal timeliness standards.
• Proficiency with medical coding concepts (ICD-10, CPT, HCPCS, DRG, ASC).
• Experience with UB-04 and CMS-1500 claim forms.
• Ability to analyze complex data, identify discrepancies, and apply contract terms accurately.
• Strong written and verbal communication skills in English.
• Effective time management skills with the ability to manage competing priorities and workload volumes.
• Intermediate proficiency with Microsoft Office applications, including Word and Excel.
• Demonstrated problem-solving skills and attention to detail.

Physical, Mental & Environmental Requirements

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. This position primarily involves sedentary work with routine use of a computer and standard office equipment. The role may require occasional light physical activity (up to 10 pounds) and brief periods of bending, reaching, or filing. The employee must be able to maintain concentration for extended periods, analyze detailed information, and meet regulatory deadlines, with or without reasonable accommodation.

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