Provider Dispute Resolutions Coordinator, Intermediate
Company: Blue Shield Of California
Location: Monterey Park
Posted on: May 3, 2021
At Blue Shield of California we are parents, leader, students,
visionaries, heroes, and providers. Everyday we come together
striving to fulfill our mission, to ensure all Californians have
access to high-quality health care at a sustainably affordable
price. For more than 80 years, Blue Shield of California has been
dedicated to transforming health care by making it more accessible,
cost-effective, and customer-centric. We are a not-for-profit,
independent member of the Blue Cross Blue Shield Association with
6,800 employees, more than $20 billion in annual revenue and 4.3
million members. The company has contributed more than $500 million
to Blue Shield of California Foundation since 2002 to have a
positive impact on California communities. Blue Shield of
California is headquartered in Oakland, California with 18
additional locations including Sacramento, Los Angeles, and San
Diego. We're excited to share Blue Shield of California has
received awards and recognition for - LGBT diversity, quality
improvement, most influential women in corporate America, Bay
Area's top companies in volunteering & giving, and one of the
world's most ethical companies. Here at Blue Shield of California,
we're striving to make a positive change across our industry and
the communities we live in - Join us!
Provider Dispute Resolution Coordinator - Accountable for formal
Provider grievance resolution. For example, resolution of
complaints and appeals, including data interpretation and review
for application of appropriate criteria and policies in line with
regulatory and accreditation requirements for provider issues.
Receives, documents, investigates, refers, and coordinates
grievances, appeals and complaints. Initiates case files for each
grievance and ensures compliance with organizational and regulatory
requirements. Typically requires two years billing, claims,
customer service, or health insurance experience and familiarity
with state and federal regulations.
- Responds to regulatory complaint inquiries, which may be
written or verbal, prompted by either/or agencies, executive
inquiries (for executives), independent medical inquiries, and
those prompted by administrative legal hearings.
- Major portion of work involves researching the data files and
developing a timeline of events, and gathering missing information
from third parties such as medical providers, to determine the
response to the inquiry, which may be: 1. Recommending alternatives
for the provider to resolve the inquiry; 2. Responding to the
inquiry (typically from an agency) with root cause analysis and any
applicable corrective action. 3. Responding with a decision (the
inquiry has no merit or the inquiry is valid) that must be
communicated and/or filed. In the event of an adverse
determination, supports an independent review by providing the
entire case file within the timeframe necessary. If the
determination is overturned, responsible for re-processing claims,
posting authorizations, and notifying the provider, medical group,
or facility of the approval within the timeframes required.
Responds to correspondence addressed to executives regarding issues
and/or concerns that an individual (member or non-member) may have.
Communication with executive would be directed through
- Other duties as assigned.
- Works to deliver on day-to-day objectives with direct impact on
achievement of results for the provider dispute resolution
- Work consists of tasks that are typically routine, with some
deviation from standard practice.
- Works under moderate supervision for routine tasks. May seek
advice of more senior personnel in the provider dispute resolution
Innovation and Complexity
- Checks and makes minor adjustments to work methods to solve
problems that are routine and typically exist in current work
processes and systems. May be required to highlight areas of
concerns/problems and put forth solutions to supervisor in provider
dispute resolution department.
- Problems and issues faced are generally routine but may require
some interpretation of procedures or policies to resolve
Communication & Influence
- Interfaces with provider relations, claims, corporate
recoveries, and configurations to identify and remediate
- Communicates with contacts typically within the provider
dispute resolution department on matters that involve obtaining or
providing information requiring some explanation or interpretation
to reach agreement.
Knowledge and Experience
- Typical level of education includes a high school diploma or
- Typically requires (2 - 4) years in health insurance operations
such as I&M, Claims, Customer Services, Regulatory Affairs
and/or Appeals/Grievances, two (2) years of which is
Appeals/grievance direct experience, or similar combination.
- Understanding of Medi-Cal claims processing required.
- Requires basic job knowledge of systems and procedures obtained
through prior work experience or education.
- Typically, requires minimum of 3 years of relevant experience.
May require vocational or technical education in addition to prior
Keywords: Blue Shield Of California, Monterey Park , Provider Dispute Resolutions Coordinator, Intermediate, Other , Monterey Park, California
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