PROVIDER DISPUTE RESOLUTION SPECIALIST

The MSO department seeks a PDR Specialist with strong verbal and written communication skills to handle provider disputes and appeals related to claims payments. This role involves researching, evaluating, and resolving claims disputes in line with regulations, policies, and industry standards. The specialist will also conduct root cause analyses, process claims readjustments, support system improvements, and manage the overpayment recoupment process.

The role requires an individual with strong analytic skills and critical thinking/problem solving skills. This individual must also have exceptional interpersonal skills to build and maintain positive working relationships.

Key Responsibilities:

- Review and resolve provider payment disputes and appeals for Medi-Cal Managed Care, Medicare Advantage, and PACE programs.

- Respond to complex provider inquiries regarding claims adjudication and payments.

- Ensure timely and accurate resolutions to disputes per regulatory guidelines.

- Maintain accurate records of dispute resolutions and update tracking systems.

- Identify and correct claims payment errors, process adjustments, and handle provider overpayment refunds.

- Analyze payment trends and escalate training or process improvement needs.

- Assist with health plan audits and other projects related to provider dispute process as required.

- Identify system configuration issues and report for resolution.

- Performs other job duties as required by manager/supervisor and NEMS Management Team.