La Jolla, California
New York, New York
New York, New York
Charleston, South Carolina
Posted: 06-Sep-24
Location: La Jolla, California
Salary: Open
Internal Number: 131863
UCSD Layoff from Career Appointment: Apply by 09/09/24 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants: Apply by 09/18/24. Eligible Special Selection clients should contact their Disability Counselor for assistance.
This position will work a hybrid schedule which includes a combination of working both onsite at Greenwich Drive and remote.
DESCRIPTION
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
MINIMUM QUALIFICATIONS
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.
PREFERRED QUALIFICATIONS
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.
SPECIAL CONDITIONS
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.
Pay Transparency Act
Annual Full Pay Range: $58,600 - $100,800 (will be prorated if the appointment percentage is less than 100%)
Hourly Equivalent: $28.07 - $48.28
Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).