Job Description

The MSO department seeks a PDR Specialist with strong verbal and written communication skills to handle provider disputes and appeals related to claims payments. This role involves researching, evaluating, and resolving claims disputes in line with regulations, policies, and industry standards. The specialist will also conduct root cause analyses, process claims readjustments, support system improvements, and manage the overpayment recoupment process.

The role requires an individual with strong analytic skills and critical thinking/problem solving skills. This individual must also have exceptional interpersonal skills to build and maintain positive working relationships.

Key Responsibilities:

• Review and resolve provider payment disputes and appeals for Medi-Cal Managed Care, Medicare Advantage, and PACE programs.
• Respond to complex provider inquiries regarding claims adjudication and payments.
• Ensure timely and accurate resolutions to disputes per regulatory guidelines.
• Maintain accurate records of dispute resolutions and update tracking systems.
• Identify and correct claims payment errors, process adjustments, and handle provider overpayment refunds.
• Analyze payment trends and escalate training or process improvement needs.
• Assist with health plan audits and other projects related to provider dispute process as required.
• Identify system configuration issues and report for resolution.
• Performs other job duties as required by manager/supervisor and NEMS Management Team.

Qualifications:

• Bachelor’s degree preferred. Associate degree with relevant experience may be considered.
• Minimum five years of experience in medical claims adjudication required.
• Strong analytical, problem-solving, and communication (written & verbal) skills.
• Knowledge of Medi-Cal & Medicare Advantage claims reimbursement and dispute resolution.
• Familiarity with healthcare compliance (HIPAA, CMS, DHCS, AB1455).
• Understanding of medical terminology, coding, and claim forms.
• Detail-oriented with strong organizational and time management skills.
• Proficiency in PC-based software and database management.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in other languages are an asset.

STATUS:

• This is an FLSA NON-exempt position.
• This is not an OSHA high-risk position.
• This is a full-time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

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