PDR Manager

posted on May 27, 2022

Job Description

Location: Anaheim, CA

Duration: Permanent

Responsibilities: 

  • 3-5 years management experience in provider dispute and provider appeals resolutions, Medicare managed care or health plan setting;
  • 5+ years experience in Medicare medical claims management in managed care setting
  • Bachelor’s degree in healthcare management or related field; and/or equivalent experience
  • Extensive knowledge of Medicare Managed Care organization determination, appeals and grievance requirements, specifically reconsideration and IRE submission requirements
  • Comprehensive knowledge of Medicare ODAG and Part C reporting
  • Strong knowledge of professional and institutional claims
  • Knowledge of claims processing systems (EZCAP preferred) and claims audit tools
  • Intermediate to Advance proficiency in MS Office products – Word, Access and Excel
  • Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements
  • Working knowledge of different claims coding requirements and payment methodology (PPS, Medicare fee schedules, etc.)
  • Ability to provide reporting requirements based on processes and/or regulatory requirements
  • Knowledge of medical terminology
  • Proven problem-solving skills and ability to translate knowledge to the department
  • Strong organizational skills and decision-making and attention to details
  • Ability to work well in a fast-paced and dynamic environment
  • Excellent presentation and training skills; group motivation and supervisory skills

 

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