We’re delighted you’re considering joining us! 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. Join Our Team! 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: 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 - Minimum years of experience required – 3 - Minimum level of education required – High School/GED - Licenses and certifications required – None. - 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. Additional Information Remote - Multiple Positions Available Salary: $28 - $32 hourly Hill Physicians is an Equal Opportunity Employer

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Auto Claims Associate Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world’s best brands? - Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. - Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world’s most respected organizations. - Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. - Leverage Sedgwick’s broad, global network of experts to both learn from and to share your insights. - Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. - Enjoy flexibility and autonomy in your daily work, your location, and your career path. - Access diverse and comprehensive benefits to take care of your mental, physical, financial, and professional needs. ARE YOU AN IDEAL CANDIDATE? To process uncomplicated auto claims within designated authority. PRIMARY PURPOSE OF THE ROLE: We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion. ESSENTIAL RESPONSIBLITIES MAY INCLUDE - Processes uncomplicated personal and commercial line property auto claims and ensures claim files are properly documented and coded correctly based on the policy. - Maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution; escalates issues as needed. - Identifies and pursues subrogation opportunities; secures and disposes of salvage. - Communicates claim action/processing with insured, client and agent or broker when appropriate. - Performs coverage, liability, and damage analysis on all claims assignments. QUALIFICATIONS Education & Licensing: One (1) year of general office experience or equivalent combination of education and experience required. Claims industry experience preferred. - High School Diploma or GED required. Bachelor's degree from an accredited college or university preferred. - Professional certification as applicable to line of business preferred. TAKING CARE OF YOU Flexible work schedule. Referral incentive program. Opportunity to work in an agile environment. Career development and promotional growth opportunities. A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $16.26-$20.00 per hour. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Support the Stop Loss Claims team by performing data entry, generating payment explanations, and preparing management reports while ensuring accuracy and attention to detail in a collaborative environment.

Role Description Our client has several openings for Remote Commercial Auto Claims Adjusters, with Bodily Injury experience, handling claims throughout the United States. - Processes moderate to complex auto commercial and personal line claims, including bodily injury and ensures claim files are properly documented and coded correctly. - Responsible for litigation process on litigated claims. - Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims. - Reports large claims to excess carrier(s). - Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution. - Identifies and pursues subrogation and risk transfer opportunities; secures and disposes of salvage. - Communicates claim action/processing with insured, client, and agent or broker when appropriate. Qualifications - Experienced in Commercial Auto Liability, Property Damage, and Bodily Injury claims. - TPA experience a plus. - Claim handling experience with authority thresholds up to $1 million. - Adjuster license in Home State, multiple states preferred. - Litigation experience preferred. - Experience working in a fast-paced environment, participating in and presenting cases to both internal and external stakeholders. Benefits - $28.00/hr + hour (based on experience) Company Description