Claims Analyst II

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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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Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Responsible for reviewing, researching, processing, and adjusting claims, including COB, according to CMS, DHMC, Health Plans, and Hill Physicians’ guidelines. Resolve/respond 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.

Job Responsibilities

Adjudicating and/or adjusting claims, while ensuring claims are handled appropriately; claim contains pertinent and correct information for processing; services are either HPMG or Health Plan financial responsibility; member is eligible for coverage on the date(s) of service; services have the required referral/authorization; accurate final claims adjudication/adjustment by using on- line computer claims payment system, which includes research on previously processed claims when needed; identify billing patterns, processing errors and/or system issues that inhibit the final adjudication of claims.

Adjudicate claims in Epic Tapestry and/or QNXT claims processing applications according to HPMG guidelines.

Process Out-of-Pocket Maximum (OOPM) notifications according to health plans and HPMG guidelines.

Ensure all claim lines are adjudicated appropriately.

Maintain departmental productivity goal. Maintain a 97% payment accuracy rate and 98% non-payment accuracy rate.

Determine benefits using automated-system controls, policy guidelines, DOFRs, and HMO Fact Sheets.

Maintain and follow-up on members’ accounts relating to coordinating of benefits.

Review and process out of network claims according to the guidelines/protocols to contain out-of-network cost.

Collect, maintain, and analyze out-of-network claims research logs to identify trends and address areas needing improvements which includes but not limited to physician/member education.

Conduct second-level review of all Medicare denials in addition to Commercial denials for “Not Authorized” and “Not A Covered Benefit”.

Research, resolve, and respond to claim resubmission appeals 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 and generate appropriate letters to member and/or providers.

Required Experience

Minimum three years of experience required.

Three years of experience in claims-payment adjudication at an IPA, Health Maintenance Organization (HMO), or Health Plan level. (Internal applicants are expected to have one year of experience in claims-payment adjudication).

Working knowledge of CPT codes, ICD-10 codes, Red Book, Revenue Codes and HCPC codes.

Ability to process all claim types on a CMS-1450 and CMS-1500 claim form, including but not limited to Surgery, Medicine, Lab and Radiology.

Ability to understand DoFRs and benefits.

Ability to calculate and convert standard drug measurements.

Knowledge of CMS and the DMHC rules and regulations.

Excellent problem solving, organizational, research and analytical skills.

Strong written- and verbal-communication skills.

Strong Word, Excel, and Access skills.

Strong interpersonal skills and the ability to interact with internal and external parties in a professional manner.

Strong judgment, decision-making and detailed oriented skills.

Ability to work independently and on a team.

Ability to work in a fast- paced environment.

Must type at least 8K-12K keystrokes on a personal computer/keyboard with 90% accuracy.

Required Education

High School/GED

Additional Information

Salary Range

$26.61 - $29.92 Hourly

Hill Physicians is an Equal Opportunity Employer

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