About the position This role involves reviewing written dispute requests from providers regarding denied or incorrect payments for both Professional and Institutional Claims. The Claims Examiner must interpret provider and health plan contracts to ensure accurate claim payments or denials, applying RBRVS and Medicare guidelines. Responsibilities include adjusting claims, identifying and escalating system or configuration issues, managing workload for efficient resolution, communicating dispute outcomes to providers in writing, and ensuring compliance with departmental guidelines. The role also requires monitoring warning reports, conducting provider education calls, accurately documenting disputes in the Provider Dispute Database for reporting, maintaining departmental quality and quantity standards, and updating the database with resolution outcomes. The Claims Examiner will also advise management of issues impacting claim processing or system configuration and perform other assigned duties.

Responsibilities

• Reviews written dispute requests from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers, regarding either Professional or Institutional Claims.
• Interprets 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.
• Adjusts claims, as appropriate, including calculation of interest and penalties due when applicable.
• Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc., affecting the Claims Departments ability to process claims accurately and forwards 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.
• Plans and organizes workload to ensure efficient and compliance resolution of issues.
• Communicates 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 department.
• Responsible for requesting special check run requests to insure compliance.
• Warning reports are monitored daily to insure compliance.
• Provider education calls completed based on outcomes of PDR.
• Responsible 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.
• Maintains minimum standards set for the department for quality and quantity of appeals received.
• Updates Provider Dispute Database with the outcome resolution of issues as appeals are completed.
• Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues.
• Advises management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.
• Performs any other assigned duties and delegated by the Management.

Requirements

• Ability to interpret provider and health plan contracts.
• Knowledge of RBRVS and Medicare guidelines.
• Proficiency in adjusting claims, including calculation of interest and penalties.
• Skill in identifying and escalating system configuration, benefits, eligibility, and authorization issues.
• Ability to plan and organize workload for efficient resolution.
• Strong written communication skills for provider correspondence.
• Experience with Provider Dispute Database or similar documentation systems.
• Ability to maintain departmental quality and quantity standards.
• Familiarity with AB1455 reporting requirements.
• Ability to advise management on claim processing and system configuration issues.

Nice-to-haves

• Experience with Professional or Institutional Claims.
• Experience with special check run requests.
• Experience conducting provider education calls.