Dispute Resolution Specialist

JOB DESCRIPTION/DUTIES:
The Dispute Resolution Specialist will receive, investigate, and resolve provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with regulatory requirements. The Specialist reviews pre-service authorizations, concurrent and post-service retroactive review, medical necessity; benefit coverage appeals and reconsiderations, and complex provider claims disputes. Requires strong knowledge of regulatory standards and regulatory deadlines. The position is further responsible for tracking, trending, and reporting complaints and appeals, as well as participating in internal and external oversight activities.

Responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.

SKILLS:

REQUIRED SKILLS/QUALIFICATIONS:
College degree or equivalent work experience.
2 to 3 years of experience in Managed Care with specific experience in resolving member and provider complaints and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
Experience working with firm deadlines, able to interpret and apply regulations.
Must be organizes, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.
A team player with excellent communication and presentation skills; must be able to work effectively with various internal departments/service areas; plan partners, participation provider groups and other external agencies.
Must be proficient MS Office applications.

PREFERRED SKILLS/QUALIFICATIONS:
Bachelor's Degree.
5-10 years experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.
Knowledge of Medical terminology and strong advocacy experience.