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Provider Dispute Resolutions Coordinator, Intermediate

Company: Blue Shield Of California
Location: Monterey Park
Posted on: May 3, 2021

Job Description:

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!


Job Summary

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 Lead/Supervisor.
  • Other duties as assigned.
    Organizational Impact
    • Works to deliver on day-to-day objectives with direct impact on achievement of results for the provider dispute resolution department.
    • 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 department.
      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 problems.
        Communication & Influence
        • Interfaces with provider relations, claims, corporate recoveries, and configurations to identify and remediate issues.
        • 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 GED.
          • 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 work experience.

Keywords: Blue Shield Of California, Monterey Park , Provider Dispute Resolutions Coordinator, Intermediate, Other , Monterey Park, California

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