Full-Time
Senior Provider Dispute Resolution Analyst
Gold Coast Health Plan
201-500 employees
Provides health plan and care coordination
Compensation Overview
$38.06 - $53.29/hr
California, USA
Remote
Open to California residents only.
Bachelor's, Associate's
 Insurance (1) |
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- A high school diploma or General Education Development (GED) credential is required.
- Knowledge of Medi-Cal, Medicare, and Dual Eligible Special Needs Plan programs, including eligibility, benefits, and managed care operations.
- Knowledge of medical billing and coding methodologies, including Current Procedural Terminology, Healthcare Common Procedure Coding System, International Classification of Diseases, Tenth Revision, Clinical Modification, International Classification of Diseases, Tenth Revision, Procedure Coding System, revenue codes, and UB-04/CMS-1500 claim forms.
- Knowledge of claims adjudication principles, encounter reporting requirements, provider reimbursement methodologies, and health plan operational workflows.
- Knowledge of Coordination of Benefits, Third Party Liability, and standard claims processing practices.
- Knowledge of state and federal healthcare regulations applicable to managed care organizations, including Medi-Cal, Medicare and Centers for Medicare & Medicaid Services requirements, and Department of Managed Health Care requirements.
- Knowledge of provider contracting concepts, Division of Financial Responsibility, reimbursement methodologies, and health plan contractual obligations.
- Knowledge of claims processing systems, encounter processing concepts, and Microsoft Office applications.
- Five years of progressively responsible experience in healthcare claims processing, provider dispute resolution, claims analysis, provider reimbursement, or a related managed care or health insurance environment.
- A valid and current driver's license, auto insurance, and applicable professional licensure are required.
- Advanced computer skills in Microsoft Office products.
- Investigate, analyze, and resolve highly complex provider disputes involving reimbursement methodologies, contractual interpretation, regulatory requirements, and claims adjudication.
- Serve as a subject matter expert by providing technical guidance and support to Provider Dispute Resolution Analysts regarding dispute research, claims adjudication, payment methodologies, and resolution activities.
- Research complex claims, payment history, benefits, authorizations, provider contracts, reimbursement methodologies, and supporting documentation to determine appropriate dispute resolution.
- Assist in resolving escalated provider disputes and collaborate with internal departments to facilitate timely and accurate resolution of complex provider payment issues.
- Identify recurring provider dispute trends, payment discrepancies, claims processing defects, and operational issues, and make recommendations for corrective actions and process improvements.
- Perform quality reviews of provider dispute work and provide coaching and feedback to promote accuracy, consistency, and regulatory compliance.
- Assist with onboarding, training, and mentoring new Provider Dispute Resolution staff while serving as a technical resource for the department.
- Monitor changes in regulatory requirements, provider contracts, reimbursement methodologies, and organizational policies to ensure consistent application within the Provider Dispute Resolution function.
- Prepare reports, analyses, and recommendations related to provider disputes, payment trends, operational performance, and compliance activities.
- Participate in cross-functional meetings and collaborate with Claims, Configuration, Provider Relations, Finance, Compliance, Information Technology, and other departments to resolve provider payment issues and improve operational performance.
- Support departmental initiatives focused on improving provider experience, operational efficiency, payment accuracy, and regulatory compliance.
- Perform other duties as assigned.
- An Associate's or Bachelor's degree in Business Administration, Healthcare Administration, Finance, or a related field is preferred.
- Experience researching and resolving highly complex provider disputes, claims adjudication, reimbursement, contractual interpretation, or provider payment issues.
- Experience providing technical guidance, mentoring staff, or serving as a subject matter expert is preferred.
- Medi-Cal, Medicare, or Medicaid managed care experience is strongly preferred.
- An equivalent combination of education, training, and experience may be considered.
Gold Coast Health Plan provides managed health care coverage for members, focusing on Medi-Cal/Medicaid and related services. Its product bundles medical care, pharmacy, preventive services, and social supports into a coordinated plan, with a care team and care management to ensure members receive appropriate services. The plan coordinates health care with social services, aiming to meet the needs of the whole person rather than just medical treatment. It differentiates itself by using leading-edge solutions to address health care challenges and by taking a local, mission-driven approach that reshapes how health care and social supports are delivered. The goal is to expand access, improve health outcomes, and redefine how health care and social services are integrated for the communities it serves.
Company Size
201-500
Company Stage
N/A
Total Funding
N/A
Headquarters
Camarillo, California
Founded
2011
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Simplify's Take
What believers are saying
- Christopher Lee joined Aug. 24, 2026, strengthening finance for H.R. 1 pressure.
- GCHP launched second-year RISE grants Feb. 20, 2026, funding coverage-retention programs.
- July 1, 2026, GCHP celebrated 15 years and nearly 225,000 members.
What critics are saying
- H.R. 1 pushes members into fee-for-service, shrinking managed-care revenue in 2026-2027.
- DHS Medicaid data-sharing controversy, June 14, 2025, erodes immigrant-family trust and enrollment.
- CalAIM dual-eligible expansion invites Kaiser and Anthem to siphon Total Care Advantage lives.
What makes Gold Coast Health Plan unique
- Ventura County monopoly-ish local Medi-Cal plan since 2011; serves 220,000 members.
- Total Care Advantage launched Oct. 1, 2025, integrating Medi-Cal and Medicare.
- RISE grants and community partnerships make GCHP a policy-active local platform.
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Benefits
Flexible Work Hours
Remote Work Options
Company News
Gold Coast Health Plan appoints new Chief Financial Officer. Aug 27, 2026, 18:12 ET Accomplished healthcare finance executive with expertise in Medi-Cal and Medicare takes the financial helm of Ventura County's local Medi-Cal and Medicare plan CAMARILLO, Calif., Aug. 27, 2026 /PRNewswire/ - Gold Coast Health Plan (GCHP) today announced the appointment of Christopher Lee as its new Chief Financial Officer (CFO). Lee brings more than 25 years of healthcare finance experience to GCHP, with deep expertise in Medicare Advantage, Medi-Cal managed care, and community health. "Christopher joins us at a critical time for our Medi-Cal members," said Dr. Felix Nuñez, GCHP's chief executive officer. "As we navigate major changes due to H.R. 1, including the transition of some members to a fee-for-service program, his proven track record of strengthening financial performance and managing costs through planning and analysis will help GCHP stay strong for our community. We are fortunate to have his experience and steady leadership on our team as we continue to grow programs like our Total Care Advantage plan." Lee comes to GCHP from Healthcare In Action, a community health organization in Southern California that serves people experiencing homelessness. As CFO, he rebuilt the organization's financial systems and strengthened how they managed grants and billing. Prior to that role, he spent seven years as vice president of financial planning and analysis at SCAN Health Plan, where he helped oversee a $5.2-billion budget and supported the plan's Medicare bid process. He also spent eight years in finance leadership roles at CareMore Health and Anthem. "As the new chief finance officer of Gold Coast Health Plan, I'm committed to building the financial infrastructure that allows this mission-driven organization to keep providing access to high-quality care and services for the people who depend on it most," said Lee. "I look forward to working with the team to build a strong financial foundation that supports our members through these major policy changes." Lee holds a master's degree in business administration from the University of Southern California and a bachelor's degree in economics from the University of California, Irvine. He started August 24. About Gold Coast Health Plan Gold Coast Health Plan proudly serves about 220,000 Medi-Cal members in Ventura County through its network of primary care physicians, specialists, behavioral health providers, and hospitals. Since it was founded in 2011, Gold Coast Health Plan has been committed to providing access to high-quality care and improving the health of its members, which include 1 in 3 county residents, 1 in 6 seniors, and 1 in 2 children up to the age of 5. To learn more, visit: www.goldcoasthealthplan.org. SOURCE Gold Coast Health Plan
Report: ACAP Safety Net Health Plans are creating innovative solutions to chronic conditions. WASHINGTON - A new report from the Association for Community Affiliated Plans (ACAP) highlights the innovative initiatives of its Safety Net Health Plans (SNHP) to address their patients' chronic conditions. It also offers a suite of policy recommendations to facilitate more effective management of chronic conditions among health plans. An estimated 60 percent of Americans live with at least one chronic disease, such as diabetes, cardiovascular disease, hypertension, or obesity. Four in 10 live with two or more such conditions. Chronic conditions account for 90 percent of the country's $4.9 trillion annual spend on health care. The prevalence of chronic conditions is particularly elevated among populations with low incomes. Among non-elderly Medicaid enrollees, 3 in 4 have at least one chronic condition. This means that ACAP-member SNHPs, which serve more than 30 million people through Medicaid, Medicare and the Health Insurance Marketplace, disproportionately care for people at greater risk of being afflicted by chronic diseases. As a result, ACAP-member plans have piloted programs that combine medical care with robust disease prevention and social support. These strategies - integrated care coordination, proactive disease management programs, data-driven quality improvement, and addressing health-related social needs - have produced numerous novel approaches from plans. "For so many of our plans' members, chronic conditions can consume their day-to-day lives," ACAP CEO Margaret A. Murray said. "However, by raising the standard of care with these innovative programs, our hope is to improve health outcomes, reduce avoidable health care spending, and return to our members a sense of control over their lives and their health." * Texas-based Community First Health Plans created an initiative aimed at helping patients living with diabetes who are at high risk of developing diabetic foot ulcers. * Health Plan of San Joaquin/Mountain Valley Health Plan of California introduced a community-based, in-person educational series on hypertension. * Gold Coast Health Plan partnered with Conejo Health, a community-based organization skilled at enhanced care management, to improve Ventura County Medical Center's follow-up after emergency department visits for substance use or mental illness. * Banner University Health Plans started offering personal educational support to Arizona families with one or more children identified as overweight to combat childhood obesity, which can lead to a higher risk for diabetes and heart disease. * Illinois-based CountyCare launched a lead poisoning awareness campaign, providing Medicaid families with educational resources and vouchers for free Brita pitchers. * Neighborhood Health Plan of Rhode Island developed a maternal meal delivery benefit, providing members who just went through childbirth with up to 28 home-delivered meals. * Chorus Community Health Plans addressed food insecurity and diabetes within the Milwaukee metro area by partnering with telehealth nutrition solution company Foodsmart while also providing medically-tailored meals as an in lieu of services benefit to qualified members. The report also details several policy recommendations to facilitate care for chronic conditions, including facilitating initiatives to support health-related social needs, addressing the looming provider shortage, improving continuity of coverage and care, and promoting fiscal sustainability through transparent rate-setting. Read the full report at www.communityplans.net. ABOUT ACAP ACAP represents 83 health plans, which collectively provide health coverage to more than 30 million people. Safety Net Health Plans serve their members through Medicaid, Medicare, the Children's Health Insurance Program (CHIP), the Marketplace and other publicly-sponsored health programs. For more information, visit communityplans.net.
CAMARILLO - Gold Coast Health Plan (GCHP) (on July 21) announced the appointment of Dr. James Cruz as its new chief medical officer (CMO), effective immediately.
CAMARILLO, Calif., June 14, 2025 /PRNewswire/ -- Gold Coast Health Plan (GCHP), the local Medi-Cal plan for Ventura County, is deeply concerned about the possibility of sensitive Medicaid enrollment data—including names, addresses, and immigration statuses—being shared with the Department of Homeland Security as reported by the Associated Press. According to the article, the data sharing was conducted "despite internal objections from Medicaid officials" and without consent from states, health plans, or members.The data includes information from individuals in various states, including California, that allow those with "unsatisfactory immigration status" to enroll in Medicaid programs funded by state dollars."This breach is not just a policy failure—it is a moral one," said Dr. Felix Nuñez, GCHP's chief executive officer. "Trust is the foundation of our health system. Undermining that trust by turning health care into a tool of immigration enforcement jeopardizes the well-being of entire communities. We must protect the right to seek care without fear."Laura Espinosa, chair of GCHP's governing board, the Ventura County Medi-Cal Managed Care Commission, said news of the data release has heightened the anxieties of a population that is already on edge due to increased activity of U.S
The governing board of Ventura County's local Medi-Cal plan approved a three-year contractCAMARILLO, Calif., April 29, 2025 /PRNewswire/ -- Gold Coast Health Plan (GCHP) today announced the appointment of Dr. Felix Nuñez as Chief Executive Officer. A seasoned family physician and health care executive with nearly three decades of experience in managed care and health care delivery, Dr. Nuñez will lead GCHP's continued commitment to delivering high-quality, equitable care to more than 240,000 Medi-Cal members in Ventura County