We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The PDR Coordinator is responsible for conducting all pertinent research in order to evaluate, respond, and resolve incoming Provider Disputes accurately, timely, and in accordance with all established regulatory guidelines.

Job Responsibilities/Duties

• Review and process all incoming Provider Disputes and appeals in accordance with all regulatory guidelines. Requires the ability to process all levels of claims and the ability to provide accurate resolution for all disputes and appeals while meeting the established standard of 40 Customer Service Forms per day.
• Provider disputes must be resolved within 45 business days to comply with DMHC guidelines.
• Handle and review projects provided by Claims Management, external providers, and internal departments. Independently run reports accordingly.
• Assist Member Services with inquiries and questions through the CSR process. Requires the ability to make necessary adjustments to errors identified on Claims payment.
• Coordinator will also need to monitor and provide responses to external providers making inquiries through the PDR direct line.
• Assist PDR Clerk with PDR acknowledgements, filing, and scanning.

Qualifications

Minimum Education: High School graduate or equivalent. College degree or equivalent education and experience preferred.

Minimum Experience: Five (5) years previous experience as medical claims adjuster or examiner. Preferably in an IPA, MSO, or Medical Group setting. Experience handling Provider calls is preferred. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements. Knowledge of CMS and DMHC regulations.

Req. Certification/Licensure: None

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/