L.A. Care Health Plan · 1 day ago
Provider Dispute Resolution Claims Examiner II
Los Angeles, CA
Full-time
Onsite
Entry, Mid Level
$61K/yr - $91K/yr
2+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, established to provide health coverage to low-income residents of Los Angeles County. The Provider Dispute Resolution Claims Examiner II is responsible for analyzing and resolving provider disputes and ensuring timely processing of claims related to L.A. Care Direct services.
FitnessGovernmentHealth Care
Responsibilities
Process all types of claims with focus on L.A. Care direct services. Claims are accurately processed within the applicable contractual or regulatory time frames. Meet production and quality standards set by PDR Claims Department Management. Timely and accurate process of standard PDR claims for all lines of business. Audit claims for excessive charges, duplicates, unbundling, and medical up coding. Resolve provider claims payment disputes. Issues are resolved within the specific time frame as required by regulatory agencies and as supported by departmental policies
Identify and report PDR trends to management for process improvement opportunities
Work with internal departments to resolve issues preventing claims processing or to enhance processing effectiveness. May assist in testing, changing, analyzing and reporting of specific enhancements
Perform other duties as assigned
Qualification
Required
Associate's Degree
At least 2 years of healthcare claims processing experience in a managed care environment with at least one year working with provider disputes
Ability to operate PC-based software programs or automated database management systems
Strong communication skills with excellent analytical and problem-solving skills
Ability to self-manage in a fast-paced, detail-oriented environment
Moderate knowledge of Microsoft Word and Excel
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (Provider Dispute Resolution (PDR), Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)-10 coding guidelines), and complete product and Coordination Of Benefits (COB) knowledge
Persuasion Skills: Persuading co-workers and management to accept recommendations for work flow or procedural changes to support process improvement efforts. In cases of provider payment dispute, Convincing the provider that their claims have been handled properly based on the provider contract or regulatory guidelines
Preferred
Bachelor's Degree
Experience processing PDR documents
Previous Medi-Cal or Medicare claims processing experience and knowledge of AB1455 regulations
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
2026-01-17
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2025-08-27
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