About Us
All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick, birthday, and vacation time as well as a 410k matching plan. Additional employee paid coverage options available.
Job Purpose
The Provider Dispute Resolution (PDR) Specialist is responsible for managing and resolving provider disputes and appeals related to claims adjudication, reimbursement, coding, or authorization determinations. The PDR Specialist ensures timely, accurate, and compliant resolution of provider disputes in alignment with regulatory requirements, contractual obligations, and organizational policies.
Duties and responsibilities
- Receive, log, and review provider disputes submitted in accordance with state, federal, and plan-specific requirements (e.g., DHCS, DMHC, CMS).
- Investigate each dispute by analyzing claims data, remittance advice, authorization records, and contractual terms.
- Coordinate with internal teams (Claims, Utilization Management, Provider Relations, Compliance) to gather relevant documentation and input needed for thorough review.
- Draft clear, accurate, and timely responses to providers in compliance with required turnaround times and documentation standards.
- Track dispute outcomes and trends, identifying recurring issues and recommending process improvements to prevent future disputes.
- Maintain detailed records and logs in tracking systems to ensure audit-readiness and compliance.
- Assist in regulatory audits and reporting related to PDR activity.
- Stay updated on changes to applicable laws, payer policies, and contracts that impact dispute resolution processes.
- Serve as a liaison to providers regarding dispute process education and support.
Qualifications
- High school diploma or equivalent required; Associate or Bachelor’s degree in healthcare administration, business, or related field preferred.
- 3+ years of experience in healthcare claims processing, dispute resolution, or provider services;
- Strong knowledge of managed care operations, provider contracting, and medical claims reimbursement methodologies (HMO, PPO, Medicare, Medi-Cal).
- Excellent analytical and problem-solving skills with a detail-oriented approach.
- Strong written and verbal communication skills.
- Ability to interpret EOBs, medical policies, and contract terms.
- Proficiency in claims adjudication systems and Microsoft Office Suite.
- Familiarity with relevant regulations (e.g., DMHC, CMS, NCQA) is a plus.
- Ability to manage multiple cases simultaneously and meet strict deadlines.
