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Claims Examiner – Provider Dispute 

resume-library  |  United States  |  

United StatesUnited States (US)
Banking & Insurance/Insurance
Work Type:
Work Time:
Full Time


Claims Examiner – Provider Dispute


A Provider Dispute Claims Examiner is responsible for analyzing and the adjudication of medical claims as it relates to managed care. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and Incidents. Collaborates with other departments and/or providers in successful resolution of claims related issues.


Intake, screen, and adjudicate provider disputes that are submitted for both Facility and Professional services rendered for all AltaMed products; Medicare, Medi-Cal, Commercial, PACE Lines of Business.

Assist with research and responding to Customer Service Inquiry calls.

Work Customer Service open inquiries and close once completed.

Adjust claims as needed based on the outcome of the Customer Service Inquiry call.

Respond to inquiries within 5 working days.

Read and interpret the provider’s dispute in order to identify how to make the provider whole in regards to the payment expected.

Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.

Read and interpret provider contracts to ensure payment/denial accuracy.

Read and interpret Medi-Cal and Medicare Fee Schedules.

Correct claims payment/denial errors identified by the Claims Auditor prior to a check run.

Must maintain an error accuracy of under 1%.

Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.

Identify root cause in order to avoid and/or minimize future provider disputes.

Assist in the creation of any business rules and training in order for the Claims Department to become more efficient and accurate.

Coordinate with the Recovery Department for any identified overpayments.

Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Attend monthly departmental meetings and provide feedback when requested.

 Other duties as assigned.


HS Diploma or GED

3+ years of Claims Processing experience in a managed care environment.

Must be knowledgeable of Medi-cal regulations.

Preferred knowledge of Medicare and Commercial rules and regulations.

Knowledge of medical terminology.

Must have an understanding to read and interpret DOFRs and Contracts.

Must have an understanding how to read a CMS-1500 and UB-04 form.

Must have strong organizational and mathematical skills.