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The Provider Claim Dispute Analyst manages the Health Plan’s provider claims dispute process and is responsible for following regulatory guidelines and Santa Clara Family Health Plan’s Provider Dispute Resolution (PDR) policy and procedure governing the logging, tracking, acknowledgement, and resolution of claims disputes submitted by providers in a manner that maintains compliance within the Medicare and Medi-Cal regulatory requirements and achieves Claims service level objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to review, research, and adjust provider claims disputes. Coordinate PDR workflow between departments or staff. Monitor the intake, logging and acknowledgment of written claims disputes to assure they are processed within regulatory timeframes. Compose and send written determination of provider disputes within regulatory timeframes. Compile and present reports, narratives, flowcharts, etc. to team and at committee meetings regarding PDR status.

REQUIREMENTS – Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

High School diploma or GED. (R) Bachelor’s Degree in Business, Healthcare Management or related field. (D) Minimum three years’ of Medi-Cal and/or Medicare claims processing experience. (R) Two years of claims appeal experience with a strong focus in Medi-Cal and/or Medicare. (D) Ability to analyze provider contracts, regulatory guidance letters, and Medi-Cal and Medicare program policy guidelines. (R) Ability to analyze, process and adjust complex claims in an accurate and timely manner; propose resolution of escalated and complex claims. (R) Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes. (R) Understanding of the relationship between the health plans, IPAs, and DOFR. (R)

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.