Dispute Specialist

The Dispute Specialist at WelbeHealth oversees and resolves first-level disputes between WelbeHealth and its contracted and non-contracted providers regarding claim payments, claim denials, and contractual agreements. This role works closely with departmental team members and internal partners to identify trends and educate providers on proper processing, ensuring compliance in all claims-related processes and promoting provider satisfaction.

Essential Job Duties:

• Examine claim records and forms to investigate and resolve first-level disputes, meeting and maintaining established quality and production standards
• Process the completion of acknowledgment and determination letters, as well as provide detailed notes on actions taken, such as dispute decision and reasoning
• Create correspondence for the Senior Examiner and work closely with leadership on improper processing trends and claim-related concerns resulting in disputes
• Establish and maintain effective working relationships with team members and interdepartmental staff and leadership
• Maintain comprehensive knowledge of claim processing guidelines, procedures, governing regulations, and compliance requirements
• Assist with the data entry of incoming clean claims in times of need

Qualifications and Requirements:

• A high school diploma or equivalency (professional experience may be substituted)
• Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment
• Minimum of three (3) years of health plan claims processing experience, and two (2) years of health plan claims dispute experience analyzing and resolving provider claims
• Strong computer and software knowledge (e.g., Excel, Outlook, PowerPoint, Word, Teams), as well as job-specific applications/systems to produce correspondence, charts, spreadsheets, and other relevant information
• Ability to navigate the complexities of state/federal websites and medical billing guidelines, using online resources to resolve outstanding claims and disputes
• Excellent verbal and written communication skills, organizational and time management skills, and problem-solving and decision-making skills