Claims Research Analyst - 25-208

Hill Physicians Medical Group•San Ramon, CA

48d•$23 - $26

About The Position

Primarily responsible for researching Claims Research & Resolution Unit's (CRRU) incoming mail while identifying PDR's and adjustments. Also responsible for researching accurate and timely claims processing administration in accordance to Health Plan (HP) contracts and HPMG's policies.

Requirements

One year internal/external experience or knowledge of claims adjudication at an IPA, Health Maintenance Organization (HMO) or HP
Working knowledge of CPT codes, ICD-10 codes, Revenue Codes and HCPC codes
Medical terminology preferred
Must type at least 40 WPM on a personal computer/keyboard
Strong research, judgment, decision-making and problem-solving skills
Ability to work independently or as a team
Strong written- and verbal-communication skills including maintaining open lines of communication within all departments of the organization
Ability to work in a fast- paced environment
Ability to focus on repetitive claims sorting detailed information
High School Diploma/GED required

Nice To Haves

Medical terminology preferred

Responsibilities

Screen and research all claims to ensure the following:
Claim contains pertinent and correct information for processing PDRs and adjustments.
Accurate final claims adjudication by using on-line computer claims payment system. This includes research on previously processed claims when needed.
Maintain 98% accuracy rate.
Maintain 100% productivity goal.
Utilize Epic to document PDRs/adjustments as needed.
Develop a CRM and generate letters as appropriate.
Complete special projects as assigned to meet department and company goals.
Identify billing patterns, processing errors, and/or system issues that inhibit the final adjudication of claims.

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