Apply on Employer Site

North East Medical Services · 10 hours ago

Provider Dispute Resolution Specialist

Burlingame, CA

Full-time

Onsite

Senior Level

5+ years exp

North East Medical Services is seeking a Provider Dispute Resolution Specialist to manage provider disputes and appeals related to claims payments. The role involves researching and resolving claims disputes, conducting root cause analyses, and supporting system improvements while maintaining strong communication with providers.

Hospital & Health Care

H1B Sponsor Likely

Hiring Manager

Adam Au

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

Qualification

Medical claims adjudicationMedi-Cal & Medicare knowledgeAnalytical skillsHealthcare compliance knowledgeProblem-solving skillsCommunication skillsMedical terminology understandingPC software proficiencyFluent in other languagesFluent in EnglishOrganizational skillsInterpersonal skillsTime management skills

Required

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

Must be able to fluently speak, read and write English

Preferred

Bachelor's degree preferred. Associate degree with relevant experience may be considered

Fluent in other languages are an asset

Benefits

Free medical, dental and vision insurance for employee, spouse and/or children

Company contribution to 401(k)

Company

North East Medical Services

North East Medical Services (NEMS) is one of the largest community health centers in the United States targeting the medically underserved Asian population.

Founded in 1968

San Francisco, CA, US

501-1000 employees

https://www.nems.org/

H1B Sponsorship

North East Medical Services has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (20)

2024 (7)

2023 (8)

2022 (5)

2021 (1)

2020 (1)