Provider Dispute Resolution Specialist - Remote (US)

NTT DATA is seeking a Remote Provider Dispute Resolution Specialist to review written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers.

Responsibilities:

Reviews, investigates and completes the resolution of Provider Disputes in writing as set forth in laws pertaining to AB1455 for Commercial Health Maintenance Organization (HMO) Enrollees of Provider Disputes and Medicare Appeals for Medicare HMO Enrollees.

• Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims.
• Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers.
• Adjust claims, as appropriate, including calculation of interest and penalties due when applicable.
• Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.
• Plan and organize workload to ensure efficient and compliance resolution of issues.
• Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
• Responsible for requesting special check run requests to ensure compliance
• Warning reports are monitored daily to ensure compliance
• Provider education calls completed based on outcomes of PDR
• Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455.
• Maintain minimum standards set for the department for quality and quantity of appeals received
• Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
• Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.
• Any other assigned duties and delegated by the Management.

Required:

• High school diploma or GED.
• 3 years of experience as a Claims Examiner with previous Medicare and HMO experience.
• 2 years of experience working with medical terminology, ICD9, ICD 10, CPT4, HCPCs, UB04 and CMS 1500 Forms
• 2 years of experience interpreting provider contract language and provisions and ability to stringently manage, decipher and adhere to Regulatory timeframes for PDR and CMS Dispute processing.
• 1 year of experience with Revenue and HCPCS coding practices
• 1 years of experience with AB1455, Knox Keene Act, Federal Register and Medicare Guidelines

Preferred:

• Xcelys Claims platform experience
• Previous auditing and appeals experience

About NTT DATA

NTT DATA is a $30 billion trusted global innovator of business and technology services. We serve 75% of the Fortune Global 100 and are committed to helping clients innovate, optimize, and transform for long-term success. We invest over $3.6 billion each year in R&D to help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have diverse experts in more than 50 countries and a robust partner ecosystem of established and start-up companies. Our services include business and technology consulting, data and artificial intelligence, industry solutions, as well as the development, implementation and management of applications, infrastructure, and connectivity. We are also one of the leading providers of digital and AI infrastructure in the world. NTT DATA is part of NTT Group and headquartered in Tokyo. Visit us at us.nttdata.com.

NTT DATA is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.

Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The hourly rate for this remote role is $18.00/hr. This rate reflects the target compensation for the position across all US locations. Actual compensation will depend on several factors, including the candidate's actual work location, relevant experience, technical skills, and other qualifications.