Full Risk Claims Specialist - 25-114

About the position

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.

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 inquiries.
• 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.

Requirements

• Minimum years of experience required - 3
• Minimum level of education required - High School/GED
• 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.
• 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 a Health Maintenance Organization (HMO) Health Plan or IPA. (Internal applicants are expected to have one year of experience in claims-payment adjudication).
• Ability to process all claim types on UB-04 and CMS 1500 claim form, including but not limited to Surgery, Medicine, Lab and Radiology.
• Ability to understand member benefits and patient cost-shares.
• 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 Microsoft application skills.
• Strong interpersonal skills and the ability to interact with employees and others in a professional manner.
• Strong judgment, decision-making and detailed oriented skills.
• Ability to work independently or as a team.
• Ability to work in a fast-paced environment.

Benefits

• Recognized as one of the 'Best Places to Work in the Bay Area'
• Recognized as one of the 'Healthiest Places to Work in the Bay Area'