Senior 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.

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 job is open to California residents only.**

• Investigate, analyze, and resolve highly complex provider disputes involving reimbursement methodologies, contractual interpretation, regulatory requirements, and claims adjudication.
• Serve as a subject matter expert by providing technical guidance and support to Provider Dispute Resolution Analysts regarding dispute research, claim adjudication, payment methodologies, and resolution activities.
• Research complex claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation to determine appropriate dispute resolution.
• Assist in resolving escalated provider disputes and collaborate with internal departments to facilitate timely and accurate resolution of complex provider payment issues.
• Identify recurring provider dispute trends, payment discrepancies, claim processing defects, and operational issues, making recommendations for corrective actions and process improvements.
• Perform quality reviews of provider dispute work and provide coaching and feedback to promote accuracy, consistency, and regulatory compliance.
• Assist with onboarding, training, and mentoring new Provider Dispute Resolution staff while serving as a technical resource for the department.
• Monitor changes in regulatory requirements, provider contracts, reimbursement methodologies, and organizational policies to ensure consistent application within the Provider Dispute Resolution function.
• Prepare reports, analyses, and recommendations related to provider disputes, payment trends, operational performance, and compliance activities.
• Participate in cross-functional meetings and collaborate with Claims, Configuration, Provider Relations, Finance, Compliance, Information Technology, and other departments to resolve provider payment issues and improve operational performance.
• Support departmental initiatives focused on improving provider experience, operational efficiency, payment accuracy, and regulatory compliance.
• Perform other duties as assigned.

• High School Graduate or General Education Degree (GED
• Knowledge of:
  Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations. Medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms. Claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows. Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices. State and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare (CMS), and Department of Managed Health Care (DMHC) requirements.
  
  Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, and health plan contractual obligations.…