Full Risk Claims Specialist - Remote (Multiple Positions) - 25-171

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At Hill Physicians Medical Group, we're shaping the healthcare of the future : actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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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 be responsible for resolving / responding to complex issues for members, health plans and physicians by conducting detailed research and by interfacing with appropriate departments and management to ensure that the standards for claims resolution processes are met. Analyst 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, Ambulance, etc.

Essential Responsibilities

• Adjudicating and / or adjusting claims, specifically for the full risk line of business, including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility, Ambulance, etc.
• Ensure these full risk claims are handled accurately, timely and appropriately.
• Claim contains pertinent and correct information for processing.
• Services have the required authorization.
• Accurate final claims adjudication / adjustment by using pricing system and provider contracts.
• Identify billing patterns, processing errors and / or system issues that inhibit the final adjudication of claims.
• Adjudicate claims on Epic Tapestry according to HPCS and HPMG guidelines.
• Navigate and decipher pricing rules using 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 goal. Maintain 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 related to claims processing with the appropriate departments as required.
• Review and process out of network claims according to the guideline / out of network claims research protocol in order to contain out-of-network cost.
• Conduct second-level review of all Medicare denials for Not Authorized and / or Not A Covered Benefit.
• Research, resolve, and respond to claim resubmission disputes and inquires.
• Coordinate and resolve claims issues related to claims processing with the appropriate departments as required. Provide claims contact resolution to the call center.
• Complete special projects as assigned to meet department and company goals.
• Document follow-up information on the system and generate appropriate letters to member and providers.

Skills and Experience Required

Additional Information

Remote - Multiple Positions Available

Salary : $28 - $32 hourly

Hill Physicians is an Equal Opportunity Employer