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Current employees can apply directly through the Internal Careers Center online for Prospect Medical job openings in California. For a streamlined application process, all you need is your four-digit employee ID number and a digital copy of your résumé handy before you apply.
Note: Internal applicants not eligible for any Sign On Bonus.
Supervisor, Provider Dispute and Resolution - Full Time, Days (PMS)
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 Supervisor is responsible for oversight, performance, and compliance for PDR department. Ensure all performance levels are met and/or exceeded. Consistently monitor goals with special emphasis on quality and completion of disputes according to regulatory guidelines.Job Responsibilities/Duties
- Monitor and manage PDR inventory daily to ensure all acknowledgements are completed within 15 working days and all provider disputes are resolved within 45 working days. Run daily PDR inventory report daily and ensure outstanding PDRs are handled timely.
- Track and trend PDRs monthly and share with entire management team. Develop and implement strategy and planning to reduce PDR inventory, improving quality results, and maximizing Claims Recovery efforts.
- Monitor the CSR inventory daily to ensure the CSRS are resolved within 45 working days.
- Review all health plan PDR audit selections prior to submitting to the health plan.
- Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan.
- Oversee the PDR Quarterly reports that are provided to the health plans. Supervisor will work alongside the data analyst to review reports and ensure accurate data is reported to Management and the health plan prior to submission.
- Process all incoming employee PDR's and appeals.
- Ensure all PDR inquiries that were sent to interface departments are answered in a timely manner.
- Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution.
- Manage, monitor, and require all direct reports to meet and/or exceed goals.
- Create measures and goals to ensure compliance with regulatory guidelines and maximize cost effectiveness for the department.
- Evaluate and assess staff on a monthly (performing 1:1's) and yearly basis, providing timely performance evaluations and implementing corrective action when necessary.
- Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members.
Minimum Education: A High School Diploma required. BS/BA or equivalent education and experience preferred.
Minimum Experience: Three (3) Years' experience in Claims Management. Five (5) Years' experience in Managed Care required. Demonstrated leadership skills, ability to coach, mentor and foster a culture of achievement. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines.
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
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.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/Position Summary
Employment Status: Regular Full-time
Work Schedule: Monday - Friday
Address: Orange - 600 City Parkway West, Suite 800
Apply on company website