RESPONSIBILITIES AND FUNCTIONSReviews 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.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 departmentResponsible for requesting special check run requests to insure complianceWarning reports are monitored daily to insure complianceProvider education calls completed based on outcomes of PDRResponsible 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 receivedUpdate Provider Dispute Database with the outcome resolution of issues as appeals are completedResponsible 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.
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