Hybrid -Provider Dispute Resolution Intake Coordinator II

Job Summary The Provider Dispute Resolution Intake Coordinator II supports the PDR unit in acknowledging Provider Dispute Resolution requests sent by providers and maintains acknowledgement compliance as regulated by Centers for Medicare and Medicaid Services (CMS) and California Department of Managed Health Care (DMHC) guidelines. The position will research Provider Disputes submitted by contracted and non-contracted providers to identify original paid or underpaid claims in MHC and other systems. Responsibilities include:

• Processing of incoming PDR's via certified mail, USPS, faxes, emails and all other sources of delivery methods.
• The Provider Dispute Resolution intake staff sorts through PDR receipts to identify and correctly route provider issues to the following departments, Grievances and Appeals, Utilization Management, Medical Management, claims production floor and the PDR unit.
• Provider dispute resolution intake staff research and identify using MHC to identify original claim being disputed by the Provider using the Provider dispute resolution process according to AB1455.
• Provider dispute resolution intake staff are responsible for keying PDR's into SSO system.
• Provider dispute resolution intake staff complete acknowledge letter and mail out correspondence letters to provider.
• Provider dispute resolution intake staff take receive calls that are forwarded from the member service department and claims provider call center regarding Provider dispute resolution inquiries. Intake staff follows up with provider regarding requested information and waiver of liability request forms that are sent on Medicare members.

Duties Processing incoming PDR's via mail/fax/email/certified mail: Opening and date stamping the mail. received from various sources; Sorting and counting mail receipts; Tracking claims receipts and apprising the department manager of high volumes; Researching claims in MHC system to identify the appealed claim by the provider; Key-in claims daily into SSO system; Verification of member eligibility using the Managed Health Care system and/or the Medi-Cal Automated Eligibility Verification System (AEVS); Identifying and forwarding misdirected mail to the correct internal departments Ensure that paper claims and nonstandard documents are routed appropriately to internal departments within the required timeframe using SSO and interoffice delivery; keeping track of Medicare member waiver request forms; Closing out cases if information has not been received in SSO. (40%) Answering phone inquiries, providing clerical assistance to the claims PDR unit as needed. Provide cross-training to other PDR intake staff. Determine workloads and process flow to ensure compliance with the regulatory agencies. (25%) Photocopying and mailing correspondence to submitting providers, PPGs, and other parties on a daily basis. Scanning/OCR uploading of PDR's and acknowledgement letters into SSO. (20%) Maintaining individual production reports: maintained on EXCEL spreadsheets. (5%) Perform other duties as assigned. (10%) Apply tot his job Apply To this Job