Dispute Resolution II

As a Provider Dispute Specialist at our organization, you will play a crucial role in reviewing provider disputes related to DRG Coding and Clinical Validation, Itemized Bill Review, and Clinical Chart Review. Your responsibilities will include submitting explanations of dispute rationale back to providers within the designated timeframe to ensure client turnaround times are met. You will be accountable for managing claim dispute volume on a daily basis, adhering to client turnaround time, and department Standard Operating Procedures. In this role, you will serve as a subject matter expert for the Expert Claim Review Team, providing support on day-to-day activities, troubleshooting, and ensuring data accuracy. Additionally, you will be responsible for creating and presenting educational material to Expert Claim Review Teams and other departments based on dispute findings. Your role will also involve research and analysis of content for bill review, utilizing strong coding and industry knowledge to maintain bill review content. Furthermore, you will be required to stay updated on regulatory changes and compliance enhancements by conducting research from multiple sources. Your support for client-facing teams regarding inquiries related to provider disputes will be crucial. Effective communication and collaboration with various teams within the organization, including the CMO and members of Expert Claim Review Product and Operations teams, will be essential to address important issues and trends. To excel in this role, you should possess a minimum of 5 years of experience in reviewing and/or auditing ICD-10 CM, MS-DRG, and APR-DRG claims. A solid understanding of audit techniques, revenue opportunities identification, and financial negotiation with providers is preferred. Knowledge of Health Insurance, Medicare guidelines, hospital coding and billing rules, and clinical skills for evaluating Medical Record Coding are necessary. In addition to technical skills, you should demonstrate strong analytical, communication, problem-solving, and project management abilities. An active Inpatient Coding Certification (e.g., CCS, CIC, RHIA, RHIT, CPC or equivalent) is required, along with a preference for a Bachelor's Degree in business, healthcare, or technology. Registered Nurse licensure is also preferred. At our organization, we are committed to fostering diversity, equity, inclusion, and belonging. We value the unique perspectives and backgrounds that each individual brings to the table. We encourage candidates from traditionally underrepresented communities to apply, including women, LGBTQIA people, people of color, and people with disabilities. We strive to make our application process accessible to all candidates and provide reasonable accommodations for qualified individuals with disabilities.,