Provider Dispute Resolution Analyst

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

**This position is open to California residents only.**

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

• Investigate, analyze, and resolve provider disputes in accordance with applicable regulatory requirements, contractual obligations, organizational policies, and established claims processing guidelines.

• Research claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation to determine appropriate dispute resolution.

• Process provider disputes accurately and within established regulatory timeframes, including acknowledgment and resolution requirements under applicable regulations.

• Communicate professionally with providers and internal business partners regarding dispute status, resolution decisions, and requests for additional information.

• Document dispute findings, research, determinations, and claim adjustments accurately within designated systems.

• Coordinate with Claims, Configuration, Provider Relations, Utilization Management, Finance, Information Technology, and other departments to facilitate timely resolution of provider disputes.

• Identify claim processing errors, payment discrepancies, system issues, and recurring operational concerns, escalating issues as appropriate.

• Monitor assigned inventory to ensure productivity, quality, and compliance standards are consistently achieved.

• Maintain current knowledge of provider contracts, reimbursement methodologies, claims adjudication practices, regulatory requirements, and departmental policies and procedures.

• Participate in departmental meetings, training activities, quality improvement initiatives, and other projects as assigned.

• Perform other duties as assigned.

MINIMUM QUALIFICATIONS

Education & Experience:

• High School Graduate or General Education Degree (GED

• Knowledge of:

o Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations.

o Medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms.

o Claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows.

o Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices.

o State and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare (CMS), and Department of Managed Health Care (DMHC) requirements.

o Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, and health plan contractual obligations.

o Claims processing systems, encounter processing concepts, and Microsoft Office applications.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

• Two (2) years of progressively responsible experience in health care claims processing, claims operations, encounter operations, managed care, provider reimbursement, or a related healthcare operational environment preferred.

• Medi-Cal/Medicaid managed care experience strongly desired.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements

• Analytical Skills: Ability to use critical thinking and reasoning to solve problems, ensuring efficient processing and sorting of incoming mail.

• Research Skills: Ability to design and conduct systematic investigations, when necessary, particularly for tracking lost or misdirected mail.

• Technical Aptitude: Proficiency in using and maintaining office equipment such as mail sorting machines, scanners, and computers, along with basic office software for tracking and managing mail.

• Problem Solving: Ability to proactively address and resolve work-related challenges, such as missing or delayed mail, in an effective and timely manner.

• Diversity Oriented: Ability to work effectively with people of varying backgrounds, age, gender, race, ethnicity, religion, or job roles, promoting a respectful and inclusive environment.

• Time Management Skills: Ability to manage time effectively to prioritize and complete mail sorting and delivery tasks within established deadlines.

• Ethical: Demonstrates conduct that aligns with a set of values and accepted standards, maintaining confidentiality and security of sensitive or confidential mail.

• Judgment: The ability to make sound decisions using available information, especially when dealing with important or urgent mail.

• Communication, Oral: Ability to effectively communicate with colleagues and recipients using clear, concise verbal communication.

• Communication, Written: Ability to accurately record and communicate mail-related information in writing, ensuring clarity and proper documentation.

• Honesty / Integrity: Ability to maintain honesty and trustworthiness in the workplace, ensuring that all activities are conducted with the highest level of integrity.

The estimated pay range for the position is:

$32.05 - $44.87

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

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At Gold Coast Health Plan, we believe that our employees are our greatest asset. We are committed to fostering a supportive and inclusive work environment where every team member can thrive. Whether you're just starting your career or looking to take the next step, we offer a range of opportunities to help you grow and succeed.

Join us in our mission to improve the health and well-being of our community. Explore our current job openings and discover how you can make a difference with Gold Coast Health Plan.