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The Provider Inquiry Manager provides leadership and oversight of claim disputes. The position involves researching and investigating claim disputes, authorizing adjustments, and referring claim disputes for further review as necessary.

Key Responsibilities:

+ Lead and oversee all claim disputes functions utilizing claim disputes system, external platforms and appropriate state and federal guidelines

+ Ensure timely, efficient, accurate and compliant resolution of claim disputes

+ Research member eligibility, correct application of benefits, prior authorizations, provider contracts, fee-schedules, claim rules and system configurations

+ Maintain and enhance claim disputes system

+ Develop, track, and analyze claim dispute reports, including but not limited to inventory, processing times, data integrity, financial impact, etc.

+ Lead special claim dispute projects

+ R eview and audit high-dollar and complex claim disputes

+ Identify opportunities to improve claims processing, and reduce risk and inefficiency

+ Analyze claim processing gaps, communicate with stakeholders and recommend process improvements leveraging analytics, automation, and AI-powered tools

+ Develop and refine claim dispute manual, SOP, workflows and policies and procedures

+ Provide on-going training and coaching to staff

+ Develop and mentor a high-performing, accountable team, fostering a culture of professional growth, operational excellence and provider-centered service

+ Work closely with the Provider Relations team to ensure claim dispute escalations are handled timely and with a high level of satisfaction

+ Collaborate with other departments to integrate best practices and enhance overall operational solutions

+ Meet performance metrics and goals established for the position

+ Performs additional duties and responsibilities as assigned by management

Qualifications:

+ Minimum of 10 years of healthcare operations or Medicare Advantage experience; strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements

+ Expertise in professional and facility claims disputes and/or appeals, claims processing, provider compensation, benefits, coding and medical terminology

+ Proven track record in strategic planning, operations and process improvement

+ Able to thrive in a complex, high-pressure environment

+ Outstanding organizational and interpersonal, written, and verbal communication skills

+ Bachelor’s degree in Business, Healthcare Administration, or a related field

+ High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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