PDR Nurse Specialist

The Provider Dispute Resolution (Nurse Specialist) will receive, investigate and resolve provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with CMS, DHCS, DMHC, MRMIB and NCQA 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:

EDUCATION:
Required: Graduate of Accredited LVN or RN Program.
License: Active, unrestricted LVN or RN CA License
Preferred: Some College

EXPERIENCE REQUIRED:
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 organized, 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:
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.