THIS IS A TEMPORARY POSITION, NOT ELIGIBLE FOR BENEFITS, CONCLUDING ON DECEMBER 31, 2026
COMPANY OVERVIEW
Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com
SUMMARY DESCRIPTION:
The Senior Provider Claims Dispute Specialist is responsible for the timely, accurate, and compliant resolution of complex provider disputes related to claims adjudication, reimbursement, coding, authorization decisions, and benefit application. This role serves as a subject matter expert for provider dispute resolution policies, CMS requirements, reimbursement methodologies, and provider contract interpretation. The position independently investigates escalated and regulatory-sensitive disputes, processes necessary claim adjustments and overpayment recoveries, conducts root cause and financial impact analyses, develops dispute reporting, and partners across the organization to improve claims accuracy, provider experience, operational performance, and compliance outcomes.
Key Responsibilities
Subject Matter Expertise
- Serve as a subject matter expert for provider dispute resolution policies, CMS requirements, and reimbursement methodologies.
- Provide guidance and consultation to Claims Operations, Provider Services, Configuration, and Compliance teams regarding dispute resolution issues.
- Interpret provider contracts, reimbursement methodologies, and regulatory requirements to support complex dispute determinations.
Complex Provider Dispute Resolution
- Independently investigate and resolve escalated, high-dollar, highly complex, and regulatory-sensitive provider disputes.
- Perform comprehensive payment reviews involving contract interpretation, authorization determinations, coding analysis, and benefit application.
- Respond to complex provider inquiries regarding claims adjudication and payment determinations.
- Ensure disputes are resolved accurately and within applicable regulatory and organizational timeframes.
- Maintain complete and accurate records of dispute research, determinations, correspondence, claim adjustments, recoveries, and related tracking activities.
Analytics and Process Improvement
- Develop and maintain dispute trending reports and dashboards.
- Analyze dispute volume, root causes, financial impact, provider patterns, payment trends, and recurring operational issues.
- Identify payment errors, process gaps, training needs, and system configuration issues; escalate findings and support corrective action.
- Contribute findings and recommendations to leadership and present information when requested to help reduce dispute volume and improve operational performance.
Regulatory Expertise and Compliance
- Maintain advanced knowledge of CMS, Medicare Advantage, Medicaid, and applicable state regulations affecting claims payment disputes.
- Conduct regulatory reviews and support implementation of regulatory changes impacting provider dispute processes.
- Apply applicable compliance requirements, including HIPAA, CMS, and state-specific requirements, when reviewing and resolving disputes.
Cross-Functional Collaboration
- Participate in cross-functional initiatives designed to improve claims accuracy, provider experience, operational efficiency, and compliance outcomes.
- Collaborate with Configuration, Provider Network, Provider Services, Quality, Compliance, Claims Operations, and IT teams to implement corrective actions.
- Provide dispute-related expertise to support operational projects and process improvements.
Audit and Financial Accountability
- Participate in dispute-related audit activities and serve as a subject matter resource, in partnership with other responsible stakeholders, during internal, external, CMS, and state regulatory audits.
- Identify and quantify financial impacts resulting from payment inaccuracies and dispute trends.
- Assist with audit requests, documentation, research, and follow-up activities related to provider disputes.
