Provider Dispute Resolution Specialist - Advanced Medical : Job Details

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Advanced Medical Management, Inc. provided pay range

This range is provided by Advanced Medical Management, Inc. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$25.00/hr - $28.00/hr

Position Summary

We are looking for a Provider Dispute Resolution Specialist (PDR Specialist) to manage and resolve disputes between our organization and healthcare providers regarding reimbursement, claims processing, and contractual agreements. The Provider Dispute Resolution Specialist will be responsible for investigating provider disputes, facilitating communication between parties, and negotiating resolution agreements. The ideal candidate will have strong analytical skills, experience in healthcare reimbursement, and a commitment to maintaining positive provider relationships.

Responsibilities and duties

• Triage incoming appeals and properly distinguish between PDRs and appeals, analyze provider disputes regarding reimbursement, claims, or contractual agreements, and transfer issues to the correct departments.
• Use internal tracking mechanisms to ensure proper processing timelines and the appropriate actions that need to be taken.
• Review and process PDRs according to CMS guidelines.
• Create proper acknowledgement letters.
• Send to appropriate departments for additional information as needed.
• Reprocess claims as needed for overturned PDRs.
• Create proper resolution letters to close PDRs timely.
• Assist in preparing and reviewing PDRs for health plan audits.
• Assist in training of other members of the PDR team as needed.
• Work with other departments as needed to make determinations on PDRs.

Education & Experience Requirements

• High School Degree required.
• 3+ years experience processing and examining claims and PDRs.
• Experience with EZCAP software is a plus.
• Understanding of different payment methodologies and financial responsibility contracts/DOFRs.
• Problem-solving skills.
• Ability to analyze claims issues and communicate changes effectively with other AMM departments.
• Expert analytical skills.
• Ability to plan and organize effectively.
• Excellent verbal and written communication skills.

Benefits

• Health Coverage: Full employer-paid HMO and optional flexible PPO plan.
• Wellness: Discounted vision and dental premiums.
• Financial: FSAs, 401(k).
• Work-Life Balance: PTO, sick pay, paid holidays.
• Career Development: Tuition reimbursement.
• Team Fun: Paid outings and lunches.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Other
• Industry: Hospitals and Health Care

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