The PDR Coordinator is responsible for the accurate review, input and adjudication of Provider Disputes to include specialty claims and UB-04’s, in accordance with outside regulations, internal production standards and contractual obligations of CHM and/or the IPA’s, on a daily basis. The PDR Coordinator is also responsible for Provider Disputes for high dollar claims, multiple surgical procedures and special handled claims. Production standards for Hospital Provider Dispute claims should be averaging 25-35 claims per day and IPA Provider Dispute claims at 50 claims per day.
Duties and Responsibilities
- Meets production standards of 25-35 Hospital Provider Dispute claims per day and 50-75 IPA Provider Dispute claims as established by claims management.
- Assists in other IPA’s when needed.
- Submits automation requests through SharePoint.
- Processes Customer Care Inquiries.
- Reviews pre-check run reports.
- Assists with training new hires.
- Performs other tasks as assigned by supervisor/manager.
- Attends training meetings and asks questions.
- Provides auditor with training suggestions/examples.
- Adhere to Claims Department policies and procedures. Keeps updated materials and resources provided for accurate and expedient adjudication.
- Ensure that the Examiner’s Checklist is verified and done.
- Provide examples of common PDRs to Supervisor.
- Provide auditor examples of examiner errors.
Minimum Job Requirements
Must have a high school diploma or equivalent. Must have knowledge of medical terminology, ICD-9, CPT-4, treatment of diagnoses, and COB.
Knowledge, Skills and Abilities Required:
- Must be able to communicate with others clearly, tactfully and professionally.
- Must be detail oriented.
- Must have strong computer skills with a broad knowledge of software packages. Must be able to follow directions and perform independently according to departmental standards when no directions are given.
- Must possess effective communication skills. Must be able to willingly accept responsibility and possess the desire to learn new tasks.
- Must speak, read and write English.
- Must have strong organizational and mathematical skills.