Provider Dispute Specialist

This position will require reporting to the Monroe or Baton Rouge office.

POSITION PURPOSE

Ensures the accurate and timely classification and processing of all provider disputes received for HMOLA and BCBSLA. Ensures the units compliance with accreditation guidelines pertaining to provider disputes. Coordinates responses to provider disputes by sending a formal letter. Complies with all laws and regulations associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, PROVIDER DISPUTES
• Necessary Contacts: In order to effectively fulfill this position, the Provider Dispute Analyst must be in contact with:
  
  Various internal and external entities including, but not limited to, all levels of BCBSLA personnel, attorneys, group leaders, members, hospitals, and physician offices.

• High School Diploma or equivalent is required.

• 4 years of health insurance experience is required.
• 2 years of experience in a customer service or provider relations environment is preferred.

• Must be able to read and interpret benefits for all lines of business.
• Must have a thorough knowledge of the claims process and adjustment procedures.
• Detailed knowledge of accreditation guidelines, state laws, and internal claims systems is necessary.
• Working knowledge of relevant PC software and applicable systems is necessary. Facets experience is required.
• Requires attention to detail, and strong record-keeping skills.
• Must demonstrate ability to work in a rapidly paced and ever-changing environment.
• Strong grammar, spelling, verbal and written communication skills are necessary.
• Presentation and public speaking skills are required.

• None Required

• Coordinates response activities between appropriate departments, conducts necessary investigation by reviewing telecommunication tapes of related and pertinent calls, as well as any documentation or claims submitted by members or providers in order to verify correct pricing and analyze claim inquiry data to determine root cause of errors to ensure contracts and reimbursement policies and procedures are priced accurately. Sends written resolution letters to appropriate parties within the required time frame for all network provider disputes in accordance with all appropriate Healthcare Accreditation entities.
• Sends out acknowledgment letters on all provider disputes within the required timeframe to notify the requester that we have received their request and to advise him/her of the timeframe in which the appeal will be resolved.
• Coordinates and host Management Level Provider Dispute meetings between internal management from various areas within the Plan and the provider or his/her representative. This includes contacting providers and relevant internal management, preparing dispute packets, and taking minutes during the meeting. Must be able to facilitate the meetings in such a way that all appropriate audience views are heard and addressed as necessary.
• Coordinates various tasks including but not limited to audits and adjustments for identified systemic problems with programming and providing onsite or telephonic education on contract related concerns in order to maintain compliance with Healthcare Accreditation entities.
• Handles other assignments, including but not limited to working the Imaging Auto Work Distribution and serving as back up to the Appeals and Grievance Analysts, to help the department reach goals and maintain compliance.Closes assigned inventory with accuracy and detail in order to address all concerns thoroughly.
• Closes assigned inventory with accuracy and detail in order to address all concerns thoroughly.
• Performs other related duties as needed,including but not limited to, back up support for other employees.
• Complies with all laws and regulations associated with duties and responsibilities.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.