Provider Dispute Resolution Specialist

Job Number6810Workplace Type : Fully RemoteRemote-US,California

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

Overview of the Role :

Alignment Health is seeking a provider dispute resolution specialist (“Specialist”) to join the claims and configuration team. As a specialist, you will process provider appeals and disputes accurately and timely, assess and complete documentation for tracking / trending data, and conduct research to respond and process incoming provider appeals and disputes in accordance with all established CMS Medicare Advantage regulatory, contractual, and departmental guidelines. You will also process the claim(s) within the claim system while following department processes, interface with internal departments and external resources and organizations and prepare and assist with departmental reports as needed.

If you’re looking for an opportunity to join a growing organization, be a part of a talented team of professionals, while positively impacting the lives of seniors – we are looking for YOU!

Responsibilities :

• Distinguish between a provider dispute and a provider appeal. Confirm each provider appeals are correctly identified for appropriate tracking and reporting
• Update tracking system to ensure cases are processed timely and appropriate actions are taken
• Review and process provider appeal and dispute determinations according to CMS, contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.
• Correspond with delegated entity to obtain appropriate records or payment information
• Prepare appropriate documentation and submit to IRE when provider appeals result in adverse determination and / or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
• Process / adjudicate claim(s) according to departmental procedures
• Meet and consistently maintain quality and productivity standards as defined by the leadership.
• Identify denial or payment variance trends and escalate to department management for training opportunities and corrective action.
• Assist in preparing and reviewing cases for regulatory and other health plan audits.
• Participate in ongoing training to support company and department initiatives.
• Support department initiatives in improving processes and workflow efficiencies
• Adhere to all regulatory and company standards, as described in the employee handbook and departmental policies and procedures.
• Comply with company’s time and attendance policy.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
• Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.

Required Skills and Experience :

Essential Physical Functions :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

PAY RANGE : $51,600 - $60,320 annually

Please note : All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception / deferral).

Alignment Health is an Equal Opportunity / Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.