Provider Dispute Representative

• Responds to routine provider inquiries via telephone assisting with provider dispute status, procedures and general inquiries
• Contacts providers to obtain missing information or provide education regarding health plan procedures
• Processes provider disputes/complaints according to established policies and procedures, including:
• Prepares provider dispute files and gathers supporting data/documentation
• Logs cases by entering information into the provider dispute database
• Prepares and sends provider dispute acknowledgement notices
• Prepares and sends dispute resolutions notices to providers
• Updates dispute log and files completed cases
• Generates provider dispute reports using Access database
• Archives provider dispute files in a retrievable manner
• Researches and resolves routine provider disputes according to procedure
• Monitors timeliness of disputes and informs manager of cases approaching deadlines
• Sends forms to providers upon request (PDR Form, Service Authorization Forms, Consultation Referral Forms, etc.)
• Prepares reports using Access and Excel
• Assists with Provider Dispute audits by gathering and organizing requested materials.
• Orders department office supplies
• Processes mailings and faxes to contracted providers
• Other duties as assigned

• • Bachelor’s degree preferred or equivalent experience.
  • Three years of experience working in managed healthcare/insurance environment, preferably in claims or provider disputes.
  • Knowledge of medical terminology and claims experience preferred.
  • Proficient Microsoft Office
  • Proficient in Excel

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.