The Provider Dispute Resolution Specialist is responsible for processing and resolving provider claim appeals, ensuring timely and accurate resolution of the claim appeal.

Key Responsibilities:

• Investigate and resolve claim appeals from providers, ensuring compliance with UCSD Health, contracted health plan, DMHC and CMS policies and applicable laws
• Review and analyze claim appeals, identifying opportunities for claim processing improvements or provider education
• Send appropriate documentation to provider, including acknowledgement letters when appropriate. Ensure that appeal resolution letters are clear, concise and meet all regulatory and contractual requirements
• Collaborate with internal departments, such as claims processing and customer service, to resolve appeal-related issues
• Analyze and interpret managed care organization policies, procedures, and applicable laws to ensure compliance and inform appeal resolution strategies
• Document and track appeal activities, maintaining accurate records and reports
• Provide training and guidance to staff on appeal procedures and best practices

• Six (6) years of related experience, education/training, OR a Bachelor's degree in related area plus two (2) years of related experience/training. Related experience - Claims processing and appeals.

• Experience and proven success in working knowledge of common organization- or research-specific and other computer application programs.

• Analyzing appeal trends including overturn and uphold rates, appeal reasons and high volume appeal submission based on provider.

• Ability to recommend improvements to claim processes and policies based on appeal trends.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.