Lead, Claims Research/Resolution Unit Analyst - 26-12

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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:

Assist the Supervisor and Claims Research & Resolution Unit (CRRU) staff in achieving the goals and objections of the unit and department. Provide technical leadership to internal staff and external customers to support optimal performance outcomes.

Essential Responsibilities:

Core Responsibilities:

• Conduct thorough research on complex claim cases and issues, effectively communicating findings to both external partners and internal stakeholders.

• Identify, analyze, and interpret departmental trends to support informed strategic decision-making, including recognizing billing patterns, processing errors, and system issues that inhibit the final adjudication of claims.

• Manage urgent claim concerns by performing detailed investigations, delivering prompt and appropriate responses, and ensuring timely and accurate resolution.

• Perform in-depth research to address service, operational, and administrative challenges, enhancing performance and fostering continuous improvement.

Lead Analyst Responsibilities:

• Collaborate closely with internal teams to set priorities and better align operations with both organizational and departmental objectives.

• Offer technical support to the Supervisor and staff to achieve the department’s objectives and expectations.

• Provide constructive feedback on operational performance, delivering prompt and actionable guidance to boost productivity and overall outcomes.

• Maintain accurate unit reports, proactively seek clarification when needed, and take decisive action as appropriate.

• Remain up-to-date with unit procedures, management technologies, and tools, consistently meeting departmental performance standards and expectations.

• Consult with external partners and internal parties as needed to facilitate effective communication and resolution of issues.

Administrative Responsibilities:

• Delegate tasks to team members, ensuring responsibilities are clearly communicated, and provide training while promptly addressing any questions from team members or the Supervisor as needed.

• Ensure that departmental policies, procedures, and practices consistently adhere to organizational standards, maintaining compliance across all operations.

• Facilitate Huddle meetings to recognize accomplishments, discuss key operational challenges, communicate ongoing initiatives, and promote open dialogue by actively encouraging information sharing, questions, and constructive feedback. 

Skills & Experience Required:

• High School diploma/GED required.

• Minimum of 3-5 years of claims processing experience required

• Must possess the technical skills of the department (such as positions that are junior to the lead analyst position- claims processing, adjustments, auditing)

• Minimum of three years' managed-care operations experience in an IPA like environment

• Working knowledge of DMHC, CMS and Health Plan requirements

• Proficient in Microsoft Word and Excel

• Excellent leadership, organizational, and communication skills (oral/written)

• Self-motivated, able to work independently

• Results oriented

Additional Information:

Salary: $30 - $33 Hourly

PriMed is an Equal Opportunity Employer