Hill Physicians Medical Group
Full Risk Claims Specialist - Remote (Multiple Positions) - 25-173
Hill Physicians Medical Group, San Ramon, California, United States, 94583
Full Risk Claims Specialist - Remote (Multiple Positions) - 25-173
Hill Physicians Medical Group
shapes the future of healthcare with actively managed care that prevents disease, supports chronic conditions, and anticipates member needs.
Join Our Team!
Hill Physicians is recognized as one of the “Best Places to Work in the Bay Area” and “Healthiest Places to Work in the Bay Area.” We value diversity and inclusion, welcoming everyone regardless of race, ethnicity, gender identity, sexual orientation, age, religion, disability, or any other attribute. We do it because it's right!
Job Description Hill Physicians Care Solutions (HPCS) is a wholly owned subsidiary of Hill Physicians and operates under a Restricted Knox‑Keene license issued by the California Department of Managed Care (DMHC). HPCS handles the highly visible and fast‑growing Medicare Advantage claims for the full risk line of business.
Under the leadership of the HPCS Supervisor, the Full Risk Claims Analyst is responsible for ensuring full risk claims and disputes are processed accurately and timely pursuant to health plan coverage and Hill Physicians' reimbursement policies, as well as within CMS and AB1455 regulations. The analyst will resolve and respond to complex issues for members, health plans, and physicians by conducting detailed research and interfacing with appropriate departments and management to meet standards for claims resolution processes.
Applicants must have experience processing full risk claims, including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility, and Ambulance claims.
Essential Responsibilities
Adjudicate and adjust full risk claims, ensuring accuracy, timeliness, and appropriateness.
Validate that claims contain pertinent and correct information for processing.
Verify required authorizations for services.
Perform final claims adjudication/adjustment using pricing system and provider contracts.
Identify billing patterns, processing errors, and system issues that impede final adjudication.
Adjudicate claims on Epic Tapestry according to HPCS and HPMG guidelines.
Navigate and decipher pricing rules using the Optum Prospective Pricing System.
Review, interpret, and process MS DRG rules, Home Health and ASC groupings, DME, and ambulance claims.
Ensure all claim lines post to the appropriate fund.
Maintain departmental productivity goals, achieving a 97% payment accuracy rate and 98% non‑payment accuracy rate in Claims Services.
Determine benefits using automated system controls, policy guidelines, and HMO Fact Sheets.
Coordinate and resolve claims issues with appropriate departments as required.
Process out‑of‑network claims according to the guideline/out‑of‑network claims research protocol.
Conduct second‑level review of Medicare denials for Not Authorized and Not Covered Benefit.
Research, resolve, and respond to claim resubmission disputes and inquiries.
Provide claims contact resolution to the call center.
Complete special projects as assigned to meet department and company goals.
Document follow‑up information in the system and generate appropriate letters to members and providers.
Skills and Experience Required
Minimum 3 years of experience in full risk claims processing.
High School diploma or GED.
Experience processing full risk claims, including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility, and Ambulance claims.
Working knowledge of CPT, Revenue codes, PDGM Home Health, ICD‑10 codes, Red Book, MS DRGs, HCPC codes, and ASC groupings.
Three years’ experience in claims‑payment adjudication at an HMO or IPA; internal applicants require one year.
Ability to process all claim types on UB‑04 and CMS 1500 claim form.
Understanding of member benefits and patient cost‑shares.
Knowledge of CMS and DMHC rules and regulations.
Excellent problem‑solving, organizational, research, and analytical skills.
Strong written and verbal communication skills.
Strong Microsoft application skills.
Strong interpersonal skills and professional interaction ability.
Strong judgment, decision‑making, and detail orientation.
Ability to work independently or as part of a team.
Adaptability to a fast‑paced environment.
Additional Information Remote – Multiple positions available.
Salary:
$28 – $32 hourly.
Hill Physicians is an Equal Opportunity Employer.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Finance and Sales
Industry Hospitals and Health Care
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shapes the future of healthcare with actively managed care that prevents disease, supports chronic conditions, and anticipates member needs.
Join Our Team!
Hill Physicians is recognized as one of the “Best Places to Work in the Bay Area” and “Healthiest Places to Work in the Bay Area.” We value diversity and inclusion, welcoming everyone regardless of race, ethnicity, gender identity, sexual orientation, age, religion, disability, or any other attribute. We do it because it's right!
Job Description Hill Physicians Care Solutions (HPCS) is a wholly owned subsidiary of Hill Physicians and operates under a Restricted Knox‑Keene license issued by the California Department of Managed Care (DMHC). HPCS handles the highly visible and fast‑growing Medicare Advantage claims for the full risk line of business.
Under the leadership of the HPCS Supervisor, the Full Risk Claims Analyst is responsible for ensuring full risk claims and disputes are processed accurately and timely pursuant to health plan coverage and Hill Physicians' reimbursement policies, as well as within CMS and AB1455 regulations. The analyst will resolve and respond to complex issues for members, health plans, and physicians by conducting detailed research and interfacing with appropriate departments and management to meet standards for claims resolution processes.
Applicants must have experience processing full risk claims, including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility, and Ambulance claims.
Essential Responsibilities
Adjudicate and adjust full risk claims, ensuring accuracy, timeliness, and appropriateness.
Validate that claims contain pertinent and correct information for processing.
Verify required authorizations for services.
Perform final claims adjudication/adjustment using pricing system and provider contracts.
Identify billing patterns, processing errors, and system issues that impede final adjudication.
Adjudicate claims on Epic Tapestry according to HPCS and HPMG guidelines.
Navigate and decipher pricing rules using the Optum Prospective Pricing System.
Review, interpret, and process MS DRG rules, Home Health and ASC groupings, DME, and ambulance claims.
Ensure all claim lines post to the appropriate fund.
Maintain departmental productivity goals, achieving a 97% payment accuracy rate and 98% non‑payment accuracy rate in Claims Services.
Determine benefits using automated system controls, policy guidelines, and HMO Fact Sheets.
Coordinate and resolve claims issues with appropriate departments as required.
Process out‑of‑network claims according to the guideline/out‑of‑network claims research protocol.
Conduct second‑level review of Medicare denials for Not Authorized and Not Covered Benefit.
Research, resolve, and respond to claim resubmission disputes and inquiries.
Provide claims contact resolution to the call center.
Complete special projects as assigned to meet department and company goals.
Document follow‑up information in the system and generate appropriate letters to members and providers.
Skills and Experience Required
Minimum 3 years of experience in full risk claims processing.
High School diploma or GED.
Experience processing full risk claims, including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility, and Ambulance claims.
Working knowledge of CPT, Revenue codes, PDGM Home Health, ICD‑10 codes, Red Book, MS DRGs, HCPC codes, and ASC groupings.
Three years’ experience in claims‑payment adjudication at an HMO or IPA; internal applicants require one year.
Ability to process all claim types on UB‑04 and CMS 1500 claim form.
Understanding of member benefits and patient cost‑shares.
Knowledge of CMS and DMHC rules and regulations.
Excellent problem‑solving, organizational, research, and analytical skills.
Strong written and verbal communication skills.
Strong Microsoft application skills.
Strong interpersonal skills and professional interaction ability.
Strong judgment, decision‑making, and detail orientation.
Ability to work independently or as part of a team.
Adaptability to a fast‑paced environment.
Additional Information Remote – Multiple positions available.
Salary:
$28 – $32 hourly.
Hill Physicians is an Equal Opportunity Employer.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Finance and Sales
Industry Hospitals and Health Care
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