Provider Dispute Resolution Analyst

Gold Coast Health Plan

. Investigate, analyze, and resolve provider disputes in accordance with regulatory requirements, contractual obligations, organizational policies, and claims processing guidelines .

Posted 10/6/2026full-timeRemote • California • United StatesJuniorMid-Level💰 $32 - $45 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in claims processing, provider reimbursement methodologies, and regulatory compliance within managed care environments. Proficient in analyzing and resolving provider disputes while maintaining accurate documentation and communication with stakeholders.

Highest-signal resume keywords

Claims ProcessingProvider Reimbursement MethodologiesMedi-Cal KnowledgeMedical Billing and CodingRegulatory Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Adjudication PrinciplesCPT CodingICD-10-CM CodingICD-10-PCS CodingRevenue CodesUB-04/CMS-1500 Claim FormsCoordination of Benefits (COB)Third Party Liability (TPL)Health Plan Operational WorkflowsEncounter Reporting Requirements

Soft Skills

CommunicationProblem SolvingCollaborationAttention to DetailTime Management

Tools & Technologies

Claims Processing SystemsMicrosoft Office Applications

Certifications & Qualifications

Valid Driver's LicenseAuto Insurance

Industry Keywords

Managed Care OperationsHealthcare RegulationsProvider ContractsMedi-CalMedicareD-SNP Programs

About the role

Key responsibilities & impact

Investigate, analyze, and resolve provider disputes in accordance with regulatory requirements, contractual obligations, organizational policies, and claims processing guidelines
Research claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation
Process provider disputes accurately within established regulatory timeframes
Communicate with providers and internal business partners regarding dispute status, resolution decisions, and additional information requests
Document dispute findings, research, determinations, and claim adjustments in designated systems
Coordinate with Claims, Configuration, Provider Relations, Utilization Management, Finance, Information Technology, and other departments
Identify claim processing errors, payment discrepancies, system issues, and recurring operational concerns, escalating as appropriate
Monitor assigned inventory to ensure productivity, quality, and compliance standards
Maintain current knowledge of provider contracts, reimbursement methodologies, claims adjudication practices, regulations, and departmental policies
Participate in departmental meetings, training, quality improvement initiatives, and assigned projects
Perform other duties as assigned

Requirements

What you’ll need

High School Graduate or General Education Degree (GED)
Knowledge of Medi-Cal, Medicare, and D-SNP programs, including eligibility, benefits, and managed care operations
Knowledge of medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms
Knowledge of claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows
Knowledge of Coordination of Benefits (COB), Third Party Liability (TPL), and standard claims processing practices
Knowledge of state and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare (CMS), and DMHC requirements
Knowledge of provider contracting concepts, DOFR, reimbursement methodologies, and health plan contractual obligations
Knowledge of claims processing systems, encounter processing concepts, and Microsoft Office applications
Two (2) years of progressively responsible experience in health care claims processing, claims operations, encounter operations, managed care, provider reimbursement, or a related healthcare operational environment preferred
Medi-Cal/Medicaid managed care experience strongly desired
Advanced computer skills in MS Office products
A valid and current Driver's License, Auto Insurance, and professional licensure(s)