Provider Dispute Resolution Analyst

3 months ago
Job ID
# of Openings Remaining
Experience (Years)


Under the general direction of the Manager, Provider Dispute Resolutions, the Provider Dispute Resolution (PDR) Analyst will review, research, and resolve complex and involved provider disputes for contracted as well as non-contracted providers in accordance with state and federal guidelines.  Conduct all pertinent research in order to evaluate, respond and close incoming Provider Disputes accurately, timely and in accordance with all established CMS and HMO regulatory guidelines. The PDR Analyst will process/adjust the disputed claim(s) accordingly within the COD database while following department processes; Interface with internal departments and external resources and assist with departmental reports as needed.


Principal responsibilities include:


· Review and process provider dispute resolutions according to state and federally defined timeframes;

· Research issues; determine the root cause of the dispute;

· Send written responses to providers in a professional manner, free of grammatical errors within required timelines;

· Answer provider inquiries regarding disputes that have been submitted;

· Maintain, track and prioritize assigned caseload through COD, provider dispute database to ensure timely completion;

· Research and evaluate contract terms, interpretation and compile necessary supporting documentation for the resolution of a provider disputed claim;

· Respond to incoming Provider Disputes accurately, timely and in accordance with all established regulatory guidelines;

· Process/Adjudicate and notates the claim accordingly within the Provider Dispute application adhering to department processes;

· Properly distinguish between a provider dispute and a provider appeal and generate and/or escalate a provider appeal for payment as appropriate and according to regulatory guidelines;

· Support management with gathering the supporting documentation during the appeals process as appropriate;

· Communicate with a variety of people, both verbally and in writing, to perform research, gather information related to the case that is under review; 

· Review and analyze provider appeals (Notice of Provider Disputes - NOPDs);

· Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed;

· Review and process complex appeals requiring a more in-depth understanding of appropriate payment methodology or denial practices, benefits, and policies and procedures, and contract interpretation;

· Research, analyze and process adjustments where interest was not applied or due on previously processed claim;

· Keep current with all policies, procedures, and regulatory guidelines to effectively interpret requirements as related to appeals;

· Sign into the Cisco phone system and answer provider calls as assigned through the phone system;

· Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance;

· Foster good relations with all departments by practicing good customer service principles (i.e., positive attitude, helpful, etc.);

· Provide technical assistance to the G&A staff as needed;

· Assist in special projects, as needed; and

· Perform other duties as assigned.



· 3+ years’ experience in claims examining, processing and adjudicating institutional and professional claims;

· Knowledge of claims processing systems;

· Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc;

· Proven problem solving skills and ability to translate knowledge to the department;

· Excellent verbal and written communication skills;

· Ability to multitask;

· Strong Organizational Skills;

· Attention to Detail; and

· Familiarity with state and federal regulatory requirements.




High School Diploma.



· Four years in a managed care claims processing environment required.




Must have detailed working knowledge of Revenue Codes, ICD-9, ICD-10, HCPCS, HCFA 1500, RBRVS, DRG and UB-92 coding and forms;
Strong interpersonal and organizational skills and detail oriented skills required;
Ability to work in cooperation with other departments and management;
Demonstrate skill working in a team-oriented structure to achieve goals;
Demonstrate skill in problem solving and research;
Demonstrate ability to maintain high standards of processing appeals accurately and productively;
Ability to correctly interpret claims processing rules, regulations, and procedures to other employees;
Ability to handle multiple projects and balance priorities as well as work for a number of individuals;
Excellent critical/analytical thinking and problem solving skills;
Ability to assume accountability, display initiative and exercise sound judgment in all areas of responsibility;
Knowledge of HealthSuite preferred; and
Proficient experience in MS Word, Excel, Access, Outlook, and PowerPoint required.


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