Sr. Manager, Provider Disputes Resolution (Remote)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Sr. Manager, Provider Disputes plays a crucial role in ensuring the effective management and resolution of provider payment disputes and post payment reviews. The Sr. Manager is responsible for the overall compliance of provider dispute processes with regulatory requirements, contractual arrangements and internal policies while maintaining a high standard of customer service satisfaction. This role manages a team of dispute resolution specialists and external vendor partners.

Job Duties/Responsibilities:

• Manages the day-to-day operations ensuring timely and accurate resolution of provider disputes.
• Develops and implements department metrics and performance standards; assists team in meeting or exceeding departmental performance standards.
• Maintains compliance in all areas of operations.
• Monitors staff production and work quality. Ensure staff fully understands expectations.
• Conducts quality audits and root-cause analyses to identify opportunities for improvement and implement corrective actions.
• Collaborate effectively with cross-functional teams and develop positive relationships with internal and external stakeholders to ensure timely and accurate resolution of payment disputes.
• Serves as the subject matter expert to assist with regulatory audits, as required, as well as prepare materials required for regulatory audit submission.
• Analyze dispute trends and root causes to identify operational gaps and recommend process improvements.
• Provides guidance and support to team members in resolving complex claim disputes.
• Develops and maintains department’s policies, procedures and workflows which support efficient and compliant provider dispute resolutions.
• Manage and oversee vendor performance, ensure contractual compliance and service level agreement.
• Lead and motivate a high-performance team through effective recruitment, onboarding, training, and retention strategies.

Job Requirements:

Experience:

• 5+ years management experience in provider dispute and provider post payment resolution in Medicare managed care or health plan setting

Education:

• Required: High School Diploma or GED.

• Preferred: Bachelor's degree in healthcare management or related field; or equivalent combination of education and experience

Specialized Skills:

• Required:

• Comprehensive knowledge of Medicare Advantage claims processing requirements, CMS reporting requirements and other related regulatory requirements
• Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements
• Extensive knowledge of different payment methodologies (PPS, Medicare fee schedules, etc.), claims coding and billing requirements
• Proven problem-solving skills and ability to translate knowledge to the department
• Proven leadership abilities with a track record of successfully managing teams, mentoring direct reports, and achieving results.
• Strong organizational and decision-making skills and attention to details
• Ability to work well in a fast-paced and dynamic environment.

Other:

Required: Intermediate to Advance proficiency in MS Office products – Word, Access, and Excel

Preferred: Hands-on experience working with claims system, Facets claims system a strong plus

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $85,696.00 - $128,543.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].