Provider Dispute Resolution Specialist
NAMM North America Medical Management - Ontario, CA

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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 and resolves written dispute requests received from providers of denied or incorrect payments.
  • Responsible for issuing denial letters and or adjudicating claims per claims policy.
  • Adjust claims, as appropriate, including calculation of interest and penalties due when applicable.
  • Ensure on hold reports are completed daily.
  • Prepare written communication to provider on the resolved disputes.
  • Responsible for accurately documenting disputes in the Provider Dispute Database.
  • Maintain minimum standards set for the department for quality and quantity of appeals received.

  • Minimum of three to five years experience as a Claims Examiner with previous Medicare and HMO experience.
  • Previous auditing and appeals experience preferred
  • Working knowledge of medical terminology, ICD9, CPT4, HCPCs.
  • Working knowledge of UB92 and HCFA 1500 Forms and FFS contract interpretations.
  • Knowledge of Excel, Word and Database programs, such as Access.
  • Extensive knowledge of HMOs.
  • Familiar with Knox Keene Act, Federal Register and Medicare Guidelines.
  • Ability to communicate effectively whether written or oral.
  • Excellent analytic skills needed.
  • Must be flexible, well organized, self –starter and a Team Player.
  • Revenue and HCPCS coding skills helpful
  • Familiarity of standard billing practices.



About this company
North American Medical Management, California, Inc. (NAMM) develops and manages provider networks, offering a full range of services to...