Brief job information:
This position is responsible for providing excellent service to providers and office staff primarily by processing provider disputes accurately and timely for Chinese Community Health Plan (CCHP) and CCHP’s Management Services Organization (MSO). Also responds to inquiries and concerns from providers and office staff.
1. Researches, investigates and resolves provider disputes, provider complaints, and other issues and inquiries related to CCHP and MSO operational procedures, claims payment, contract interpretation, provider network issues and utilization management issues. 2. Monitors Provider Dispute Resolution (PDR) cases to ensure completion within required time frames. 3. Processes provider disputes/complaints according to established policies and procedures, including: o Prepares provider dispute files and gathers supporting data/documentation o Logs cases by entering information into the provider dispute database o Prepares and sends provider dispute acknowledgement notices o Prepares and sends dispute resolutions notices to providers o Updates dispute log and files completed cases o Generates provider dispute reports using Access database o Archives provider dispute files in a retrievable manner 4. Contacts providers to obtain missing information or provide education regarding health plan procedures. 5. Presents dispute case files for Medical Director and/or Physician Reviewer review. 6. Coordinates provider dispute audits by gathering and organizing requested materials and meeting with auditors. When required, recommends and writes corrective action plans. 7. Identifies and recommends opportunities for improvement resulting from provider disputes and provider inquiries. 8. Receives and responds to telephone inquiries from providers and office staff. 9. Educates providers and office staff on operational policies and procedures. 10. Writes informational and educational letters in response to provider disputes. 11. Prepares reports using the Core System, Access, and Excel. 12. Maintains updated versions of the Provider Dispute Policy and Procedure Manual. 13. Writes policies and procedures as assigned by the UM Manager or CCHP Medical Director. 14. Orders department office supplies. 15. Processes mailings and faxes to providers. 16. Accepts and performs other duties as assigned.