Salary Range: $62,166 - $93,250
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status:Non-Exempt
Department:Claims
Reports To:Claims Supervisor, Manager, or Director

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

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.

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

1. 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.
2. Coordinate PDR workflow between departments or staff.
3. Monitor the intake, logging and acknowledgment of written claims disputes to assure they are processed within regulatory timeframes.
4. Compose and send written determination of provider disputes within regulatory timeframes.
5. Compile and present reports, narratives, flowcharts, etc. to team and at committee meetings regarding PDR status.
6. Prepare for and participate in Health Plan PDR audits conducted by regulatory agencies.
7. Participate in system testing and communicate newly-identified and potential issues to the Claims Supervisor, Manager or Director and provide recommendations for improvement and resolution.
8. Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions.
9. Perform other related duties as required or assigned.

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High School diploma or GED. (R)
2. Bachelor's Degree in Business, Healthcare Management or related field. (D)
3. Minimum three years' of Medi-Cal and/or Medicare claims processing experience. (R)
4. Two years of claims appeal experience with a strong focus in Medi-Cal and/or Medicare. (D)
5. Ability to analyze provider contracts, regulatory guidance letters, and Medi-Cal and Medicare program policy guidelines. (R)
6. Ability to analyze, process and adjust complex claims in an accurate and timely manner; propose resolution of escalated and complex claims. (R)
7. Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes. (R)
8. Understanding of the relationship between the health plans, IPAs, and DOFR. (R)
9. Ability to conduct all necessary research to accurately identify complex claims issues and determine appropriate resolution. (R)
10. Ability to consistently meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards. (R)
11. Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule. (R)
12. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R)
13. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
14. Working knowledge of QNXT claims processing software. (D)
15. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
16. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
17. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
18. Ability to maintain confidentiality. (R)
19. Ability to comply with SCFHP's policies and procedures. (R)
20. Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

General office conditions. May be exposed to moderate noise levels.

EOE