Medicare Full-Risk Claims Specialist

Jobfu; San Ramon (CA); On-site; USD 39,000 - 44,000; Full time

Job summary

Hill Physicians Medical Group in San Ramon, CA is seeking a Full Risk Claims Specialist to process Medicare Advantage claims across multiple lines. The role requires deep knowledge of MS DRG inpatient, ASC, home health care, DME, and related coding and pricing rules.

You will adjudicate claims on Epic Tapestry, ensure accuracy, and respond to complex disputes while maintaining high productivity and compliance with CMS and DMHC guidelines.

Qualifications

• Experience processing full risk claims including MS DRG inpatient, ASC, home health and more.
• Working knowledge of CPT, Revenue codes, PDGM Home Health, ICD-10, MS DRGs, HCPC codes.
• Three years’ claims-payment adjudication experience in an HMO or IPA.

Responsibilities

• Adjudicate and adjust full risk claims across multiple service lines.
• Ensure claims are accurate, timely and compliant with policies.
• Review pricing rules and provider contracts for final adjudication.
• Identify processing errors and system issues affecting payments.
• Adjudicate on Epic Tapestry per guidelines and pricing systems.
• Handle out-of-network claim reviews per protocol.
• Research and respond to claim resubmission disputes and inquiries.
• Document follow-up information and generate member/provider letters.

Skills

Managed Care

Disabilities

Medicare

Leadership

Research

Management

Claims Resolution

Surgery

Home Health Care

Nursing

Adjudication

Billing

Epic Tapestry

Fact Sheets

Claims Processing

Health Maintenance

Radiology

Problem Solving

Analytical Skills

Education

High School/GED

Tools

Epic Tapestry

Job description

Hill Physicians Medical Group in San Ramon, CA is seeking a Full Risk Claims Specialist to process Medicare Advantage claims across multiple lines. The role requires deep knowledge of MS DRG inpatient, ASC, home health care, DME, and related coding and pricing rules.

You will adjudicate claims on Epic Tapestry, ensure accuracy, and respond to complex disputes while maintaining high productivity and compliance with CMS and DMHC guidelines.